THANK YOU FOR TAKING THE TIME TO COMPLETE AN EXPRESS APP FOR BLACKROCK LOGISTICS BY TAKING THE TIME TO COMPLETE ALL THE REQUIRED INFORMATION, YOU WILL EXPEDITE THE PROCESS OF HAVING YOUR APPLICATION CONSIDERED FOR AN OPEN POSITION. THIS APPLICATION REQUIRES INTERNET EXPLORER or MOZILLA FIREFOX TO COMPLETE. PLEASE READ THE FOLLOWING IMPORTANT REMINDERS BEFORE PROCEEDING. PAGE 1.1 THREE YEAR'S ADDRESSES - If you have lived less than 3 years at your current address, provide additional addresses and the lenght of time at each in the space provided. EMPLOYMENT HISTORY - Federal law required motor carriers to confirm a minimum of three years previous employment, and for CDL drivers obtain up to 10 years employment history. Use the space at the bottom of Page 1.1 to list your employment history if necessary. NOTE - You will need COMPLETE previous employment address and contact information for a minimum of 3 years of past employment. PERIODS OF UNEMPLOYMENT - Record periods of unemployment when they occurred, entering "Unempl" in all fields except the phone number field - enter your phone number in this field when unemployed. PAGE 1.2 ACCIDENTS - If you have no accidents to record, enter "None" in the date space. TRAFFIC CONVICTIONS - If you have no traffic convictions & forfeitures to list, enter "None" in the date space. PRINT & SUBMIT - When you have completed pages 1.1 and 1.2, click on the "Print" button to produce a hardcopy for your records, then click on the "Email" button to submit your completed Express App. TECHNICAL SUPPORT - For assistance call (503) 922-2009. NOTICE TO APPLICANT: COMPLETE PAGES 1.1 AND 1.2 ONLY. PAGES 2.1-2.4 ARE FOR EMPLOYER USE ONLY. CHANGING ANY INFORMATION ON THESE PAGES WILL INVALIDATE THE APPLICATION. By selecting "I agree" from the list below, you grant BLACK ROCK LOGISTICS permission to contact previous employers and complete other preliminary investigations to qualify your application for consideration.
APP MVR PEI MED D&A ROAD Application Date QuickFile EXPRESS Applications DRIVER'S APPLICATION FOR EMPLOYMENT BlackRock Logistics 5870 Stoneridge Mall Rd, Ste 108 Pleasanton, CA 94588 1.1 Applicant's Name Phone Number Email Address Position Applied For Current Address and the number of years at this address. # Years here SSN Date of Birth If less than 3 years at the current address, enter all additional addresses, including the length of time at each for the past 3 years. ENTER 'None' IF NONE ARE REQUIRED. EMPLOYMENT HISTORY - List all employment for the past 10 years. Include any periods of unemployment, showing the 'Start' and 'Ending' dates. Be sure to include contact information for each employer. 1. Most Recent Employer Was your position subject to the FMCSR? From (Mon/Year) To (Mon/Year) Position Held Was the job designated 'Safety Sensitive'? Contact Person Complete Address Phone Number Reason for leaving Rate of Pay 2. Next Employer (If unemployed, enter "Unempl) Was your position subject to the FMCSR? From (Mon/Year) To (Mon/Year) Position Held Was the job designated 'Safety Sensitive'? Contact Person Complete Address Phone Number Reason for leaving Rate of Pay 3. Next Employer (If unemployed, enter "Unempl) Was your position subject to the FMCSR? From (Mon/Year) To (Mon/Year) Position Held Was the job designated 'Safety Sensitive'? Contact Person Complete Address Phone Number Reason for leaving Rate of Pay 4. Next Employer (If unemployed, enter "Unempl) Was your position subject to the FMCSR? Was the job designated 'Safety Sensitive'? Contact Person Complete Address From (Mon/Year) To (Mon/Year) Position Held Phone Number Reason for leaving Rate of Pay If less than 10 years of employment is listed above, include additional employment here. BE SURE TO INCLUDE STARTING & ENDING DATES.
You have the right to (1) review information provided by previous employers upon submitting a written request within 30 days after being notified of denial of employment; (2) have errors in information corrected; and (3) have a rebuttal statement attached to alleged erroneous information. By typing your initials in this box you signify that you have read and understand your rights stated here. PERMANANT RECORD 1.2 ACCIDENT RECORD FOR PAST 3 YEARS. IF NONE, WRITE "None". Date of last accident Nature of accident Were there any injuries/fatalities? Date of next accident Nature of accident Were there any injuries/fatalities? TRAFFIC CONVICTIONS & FORFEITURES FOR PAST 3 YEARS. IF NONE, WRITE "None". Date of most recent Date next Charge - choose from list or type your own Charge - choose from list or type your own Others - Include date & charge LIST CURRENT LICENSE & ALL LICENSE HELD FOR PAST 5 YEARS. Current License State Expiration date Endorsements List other license held in past 5 years EXPERIENCE - CHECK ALL THAT APPLY. Straight Truck How many miles or years? Truck/Trailer How many miles or years? Dry Van How many miles or years? Reefer How many miles or years? Flatbed How many miles or years? Doubles How many miles or years? Triples How many miles or years? Tanker How many miles or years? Other - Specify In the past 2 years, have you tested positive, or refused to take a pre-employment drug/alcohol test for a safety sensitive position and were not hired? Have you ever been denied a license, permit or driving privilege, or had it suspended, revoked? If 'yes', explain. I understand that the employment information I provided in the Employment History section of this application may be used, and my previous employers will be contacted for the purpose of investigating my safety performance history as required by 49 CFR 391.23(d) and (e). I hereby authorize BlackRock Logistics and its agents to contact my former employers and verify the information contained herein. By typing my initials in this box, I certify that this application was completed by me, and that all entries on it and information in it are true and complete to the best of my knowledge. Dated
SAFETY PERFORMANCE HISTORY INVESTIGATION PERMANANT RECORD 1st Attempt Ph/Fax/Mail 2nd Attempt Ph/Fax/Mail 3rd Attempt Ph/Fax/Mail Person making contacts must initial each attempt. 2.1 Employer Address Contact Phone Fax Applicant SSN I authorize the release of information to BlackRock Logistics & its Agents for the purpose of investigations required by 49 CFR 391.23, 382.413 and 40.25 of the Federal Motor Carrier Regulations. You are released from any and all liability which may result from furnishing such information. Information provided by you is subject to the provisions of 49 CFR 391.23 (c)(1),(2) and (3). RETURN TO: BlackRock Logistics 5870 Stoneridge Mall Rd, Ste 208 Pleasanton, CA 94588 or FAX (925) 426-1013 Applicant's Signature: Verified by: Dated THE ABOVE NAMED PERSON HAS MADE APPLICATION TO THIS COMPANY AS A DRIVER AND STATES THAT HE/SHE WAS EMPLOYED BY YOU IN THE POSTION & FOR THE DATES SHOWN HERE. PLEASE CONFIRM AND/OR UPDATE THIS INFORMATION ACCORDING TO YOUR RECORDS. Position From To Accurate [ ] Actual 1. Did he/she drive a commercial motor vehicle as defined in 49 CFR 390.5 or 383.5? [ ] Yes [ ] No 2. If "yes", what kind of vehicle? [ ]Straight truck [ ]Truck/Trailer [ ]Tanker [ ] Other (specify): 3. Was he/she involved a motor vehicle accident as defined in 49 CFR 390.5? [ ] Yes [ ] No 4. If he/she was involved in an accident as defined in 49 CFR 390.5, please provide: Date of accident: Location: Number of injuries/fatalities: Was Hazmat released? [ ]Yes [ ] No 5. Reason for leaving your company? [ ] Discharged [ ] Resigned [ ] Lay Off [ ] Other: Eligible for rehire [ ] Yes [ ] No 6. Other comments: IF THIS APPLICANT WAS SUBJECT TO 49 CFR 382 DRUG & ALCOHOL TESTING IN THE PAST 3 YEARS, DID HE/SHE: Have an alcohol test with a result of 0.04 alcohol concentration or greater while your employee? No Yes Have a verified positive controlled substances test while in your employment? No Yes Refuse to complete a drug or alcohol test required under Part 382 while in your employment? No Yes Violate drug and alcohol regulations of any other DOT agency? No Yes If the answer to any of the above four questions is Yes, can you provide documentation of the applicant's successful completion of return-to-duty process? No Yes Did he/she subsequent to completing the SAP's rehabilitation referral have an alcohol test with a result of 0.04 or higher, a verified positive drug test, or refuse to be tested? No Yes APPLICANT'S CONSENT: I,, CONSENT TO THE RELEASE OF THE SPECIFIC INFORMATION REQUIRED UNDER 49 CFR 40.25; 382.413; AND 382.405(f) TO THIS INQUIRING PROSPECTIVE EMPLOYER. Dated: to Name & title of person supplying information Date:
SAFETY PERFORMANCE HISTORY INVESTIGATION PERMANANT RECORD 1st Attempt Ph/Fax/Mail 2nd Attempt Ph/Fax/Mail 3rd Attempt Ph/Fax/Mail Person making contacts must initial each attempt. 2.2 Employer Address Contact Phone Fax Applicant SSN I authorize the release of information to BlackRock Logistics & its Agents for the purpose of investigations required by 49 CFR 391.23, 382.413 and 40.25 of the Federal Motor Carrier Regulations. You are released from any and all liability which may result from furnishing such information. Information provided by you is subject to the provisions of 49 CFR 391.23 (c)(1),(2) and (3). RETURN TO: BlackRock Logistics 5870 Stoneridge Mall Rd, Ste 208 Pleasanton, CA 94588 or FAX (925) 426-1013 Applicant's Signature: Verified by: Dated THE ABOVE NAMED PERSON HAS MADE APPLICATION TO THIS COMPANY AS A DRIVER AND STATES THAT HE/SHE WAS EMPLOYED BY YOU IN THE POSTION & FOR THE DATES SHOWN HERE. PLEASE CONFIRM AND/OR UPDATE THIS INFORMATION ACCORDING TO YOUR RECORDS. Position From To Accurate [ ] Actual 1. Did he/she drive a commercial motor vehicle as defined in 49 CFR 390.5 or 383.5? [ ] Yes [ ] No 2. If "yes", what kind of vehicle? [ ]Straight truck [ ]Truck/Trailer [ ]Tanker [ ] Other (specify): 3. Was he/she involved a motor vehicle accident as defined in 49 CFR 390.5? [ ] Yes [ ] No 4. If he/she was involved in an accident as defined in 49 CFR 390.5, please provide: Date of accident: Location: Number of injuries/fatalities: Was Hazmat released? [ ]Yes [ ] No 5. Reason for leaving your company? [ ] Discharged [ ] Resigned [ ] Lay Off [ ] Other: Eligible for rehire [ ] Yes [ ] No 6. Other comments: IF THIS APPLICANT WAS SUBJECT TO 49 CFR 382 DRUG & ALCOHOL TESTING IN THE PAST 3 YEARS, DID HE/SHE: Have an alcohol test with a result of 0.04 alcohol concentration or greater while your employee? No Yes Have a verified positive controlled substances test while in your employment? No Yes Refuse to complete a drug or alcohol test required under Part 382 while in your employment? No Yes Violate drug and alcohol regulations of any other DOT agency? No Yes If the answer to any of the above four questions is Yes, can you provide documentation of the applicant's successful completion of return-to-duty process? No Yes Did he/she subsequent to completing the SAP's rehabilitation referral have an alcohol test with a result of 0.04 or higher, a verified positive drug test, or refuse to be tested? No Yes APPLICANT'S CONSENT: I,, CONSENT TO THE RELEASE OF THE SPECIFIC INFORMATION REQUIRED UNDER 49 CFR 40.25; 382.413; AND 382.405(f) TO THIS INQUIRING PROSPECTIVE EMPLOYER. Dated: to Name & title of person supplying information Date:
SAFETY PERFORMANCE HISTORY INVESTIGATION PERMANANT RECORD 1st Attempt Ph/Fax/Mail 2nd Attempt Ph/Fax/Mail 3rd Attempt Ph/Fax/Mail Person making contacts must initial each attempt. 2.3 Employer Contact Applicant Address Phone SSN Fax I authorize the release of information to BlackRock Logistics & its Agents for the purpose of investigations required by 49 CFR 391.23, 382.413 and 40.25 of the Federal Motor Carrier Regulations. You are released from any and all liability which may result from furnishing such information. Information provided by you is subject to the provisions of 49 CFR 391.23 (c)(1),(2) and (3). RETURN TO: BlackRock Logistics 5870 Stoneridge Mall Rd, Ste 208 Pleasanton, CA 94588 or FAX (925) 426-1013 Applicant's Signature: Verified by: Dated THE ABOVE NAMED PERSON HAS MADE APPLICATION TO THIS COMPANY AS A DRIVER AND STATES THAT HE/SHE WAS EMPLOYED BY YOU IN THE POSTION & FOR THE DATES SHOWN HERE. PLEASE CONFIRM AND/OR UPDATE THIS INFORMATION ACCORDING TO YOUR RECORDS. Position From To Accurate [ ] Actual 1. Did he/she drive a commercial motor vehicle as defined in 49 CFR 390.5 or 383.5? [ ] Yes [ ] No 2. If "yes", what kind of vehicle? [ ]Straight truck [ ]Truck/Trailer [ ]Tanker [ ] Other (specify): 3. Was he/she involved a motor vehicle accident as defined in 49 CFR 390.5? [ ] Yes [ ] No 4. If he/she was involved in an accident as defined in 49 CFR 390.5, please provide: Date of accident: Location: Number of injuries/fatalities: Was Hazmat released? [ ]Yes [ ] No 5. Reason for leaving your company? [ ] Discharged [ ] Resigned [ ] Lay Off [ ] Other: Eligible for rehire [ ] Yes [ ] No 6. Other comments: IF THIS APPLICANT WAS SUBJECT TO 49 CFR 382 DRUG & ALCOHOL TESTING IN THE PAST 3 YEARS, DID HE/SHE: Have an alcohol test with a result of 0.04 alcohol concentration or greater while your employee? No Yes Have a verified positive controlled substances test while in your employment? No Yes Refuse to complete a drug or alcohol test required under Part 382 while in your employment? No Yes Violate drug and alcohol regulations of any other DOT agency? No Yes If the answer to any of the above four questions is Yes, can you provide documentation of the applicant's successful completion of return-to-duty process? No Yes Did he/she subsequent to completing the SAP's rehabilitation referral have an alcohol test with a result of 0.04 or higher, a verified positive drug test, or refuse to be tested? No Yes APPLICANT'S CONSENT: I,, CONSENT TO THE RELEASE OF THE SPECIFIC INFORMATION REQUIRED UNDER 49 CFR 40.25; 382.413; AND 382.405(f) TO THIS INQUIRING PROSPECTIVE EMPLOYER. Dated: to Name & title of person supplying information Date:
SAFETY PERFORMANCE HISTORY INVESTIGATION PERMANANT RECORD 1st Attempt Ph/Fax/Mail 2nd Attempt Ph/Fax/Mail 3rd Attempt Ph/Fax/Mail Person making contacts must initial each attempt. 2.4 Employer Contact Applicant Address Phone SSN Fax I authorize the release of information to BlackRock Logistics & its Agents for the purpose of investigations required by 49 CFR 391.23, 382.413 and 40.25 of the Federal Motor Carrier Regulations. You are released from any and all liability which may result from furnishing such information. Information provided by you is subject to the provisions of 49 CFR 391.23 (c)(1),(2) and (3). RETURN TO: BlackRock Logistics 5870 Stoneridge Mall Rd, Ste 208 Pleasanton, CA 94588 or FAX (925) 426-1013 Applicant's Signature: Verified by: Dated THE ABOVE NAMED PERSON HAS MADE APPLICATION TO THIS COMPANY AS A DRIVER AND STATES THAT HE/SHE WAS EMPLOYED BY YOU IN THE POSTION & FOR THE DATES SHOWN HERE. PLEASE CONFIRM AND/OR UPDATE THIS INFORMATION ACCORDING TO YOUR RECORDS. Position From To Accurate [ ] Actual 1. Did he/she drive a commercial motor vehicle as defined in 49 CFR 390.5 or 383.5? [ ] Yes [ ] No 2. If "yes", what kind of vehicle? [ ]Straight truck [ ]Truck/Trailer [ ]Tanker [ ] Other (specify): 3. Was he/she involved a motor vehicle accident as defined in 49 CFR 390.5? [ ] Yes [ ] No 4. If he/she was involved in an accident as defined in 49 CFR 390.5, please provide: Date of accident: Location: Number of injuries/fatalities: Was Hazmat released? [ ]Yes [ ] No 5. Reason for leaving your company? [ ] Discharged [ ] Resigned [ ] Lay Off [ ] Other: Eligible for rehire [ ] Yes [ ] No 6. Other comments: IF THIS APPLICANT WAS SUBJECT TO 49 CFR 382 DRUG & ALCOHOL TESTING IN THE PAST 3 YEARS, DID HE/SHE: Have an alcohol test with a result of 0.04 alcohol concentration or greater while your employee? No Yes Have a verified positive controlled substances test while in your employment? No Yes Refuse to complete a drug or alcohol test required under Part 382 while in your employment? No Yes Violate drug and alcohol regulations of any other DOT agency? No Yes If the answer to any of the above four questions is Yes, can you provide documentation of the applicant's successful completion of return-to-duty process? No Yes Did he/she subsequent to completing the SAP's rehabilitation referral have an alcohol test with a result of 0.04 or higher, a verified positive drug test, or refuse to be tested? No Yes APPLICANT'S CONSENT: I,, CONSENT TO THE RELEASE OF THE SPECIFIC INFORMATION REQUIRED UNDER 49 CFR 40.25; 382.413; AND 382.405(f) TO THIS INQUIRING PROSPECTIVE EMPLOYER. Dated: to Name & title of person supplying information Date:
Pre-Employment Screening Program (PSP) Operator -Application consent INSTRUCTIONS: PSP account holders are required by federal law (49 U.S.C.31150) to obtain an operator-application written consent prior to accessing the driver's PSP report. The FMCSA requires that the consent form use the language provided in paragraphs 1-4-below. Motor carriers may request PSP records solely for the purpose of conduction pre-employment screening. 1.In connection with your application with BlackRock Logistics ("Perspective Employer") it may obtain one or more reports regarding your driving, and safety inspection history from the Federal Motor Carrier Safety Administration (FMCSA). When the application for employment is submitted in person, if the Prospective Employer uses any information it obtains from FMCSA in a decision to not he you or to make any other adverse employment decision regarding you, the Prospective Employer will provided you with a copy of the report upon which its decision was based a written summary of your rights under the Fair Credit Reporting Act before taking any final adverse action. If any final adverse action is taken against you based upon your driving history or safety report, the Prospective Employer will notify you that the action has been taken and that action was based in part or in whole on this report. When the application for employment is submitted by mail, telephone, computer or other similar means, if the Prospective Employer uses any information it obtains from FMCSA in a decision to not hire you or to make any other adverse employment decision regarding you, the Prospective Employer must provide you within three business days of taking adverse action oral, written or electronic notification: that adverse action has been taken based in whole or in part on information obtained from FMCSA; the name, address and the toll free telephone number of FMCSA; that the FMCSA did not make the decision to take the adverse action and is unable to provide you the specific reasons why the adverse action was taken; and that you may, upon providing proper identification, request a free copy of the report and may dispute with the FMCSA the accuracy or completeness of any information or report. If you request a copy of a driver record from the Prospective Employer who procured the report, then within 3 business days of receiving your request, together with proper identification, the Prospective Employer must send or provide to you a copy of your report and a summary of your rights under the Fair Credit Reporting Act. The Prospective Employer cannot obtain background reports from FMCSA unless you consent in written. If you agree that the Prospective Employer may obtain background reports, please read the following and sign below. 2. I authorize BlackRock Logistics ("Prospective Employer") to access the FMCSA Pre-Employment Screening Program (PSP) system to seek information regarding my commercial driving safety record and information regarding my safety inspection. I understand that I am consenting to the release of safety performance information including crash data from the previous five (5) years and inspection history from the previous three (3) years. I understand and acknowledge that this release of information may assist the Prospective Employer to make determination regarding my suitability as an employee. 3. I further understand that neither the Prospective Employer nor the FMCSA contractor supplying the crash and safety information has the capability to correct any safety data that appears to be incorrect. I understand I may challenge the accuracy of the data by submitting a request to https://dataqs/ fmcsa.dot.gov. If I am challenging crash or inspection information reported by the State, FMCSA cannot change or correct this data. I understand my request will be forwarded by the DataQs system to the appreciate State for adjudication. 4. Please note: Any crash or inspection in which you were involved will display on your PSP report. Since the PSP report does not report, or assigned or imply fault, it will include all Commercial Motor Vehicle (CMV) crashes where you were a driver or co-driver and where those crashes were reported to FMCSA, regardless of fault. Similarly, all inspections, with or without violations, appear on the PSP report. State citations associated with FMCSA violations that have been adjudicated by a court of law will also appear, and remain, on a PSP report. I have read above PSP Operator-Applicant Consent notice provided to me by Prospective Employer and I understand that if I sign this consent form, Prospective Employer may obtain a report of my crash and inspection history. I hereby authorize Prospective Employer and its employees, authorized agents, and/or affiliates to obtain the information authorized above. Date Signature Print Name: Rev: JD: 12/30/2013
FAIR CREDIT REPORTING ACT DISCLOSURE STATEMENT In accordance with the provisions of Section 604(b)(2) of the Fair Credit Reporting Act, Public Law 91-508, as amended by the Consumer Credit Reporting Act of 1996 (Title II, Subtitle D, Chapter I, of Public Law 104-208), you are being informed that reports verifying your previous employment, previous drug and alcohol test results, and your driving record may be obtained on you for employment purposes. These reports are required by Sections 382.413.391.23, and 391.25 of the Federal Motor Carrier Safety Regulations. Applicant's Signature Date Print Name Social Security Number Rev. BRL 01/02/2014
APPLICANT'S NAME: SOCIAL SECURITY NUMBER REQUEST FOR CHECK OF DRIVING RECORD I hereby authorized the release of Motor Vehicle Record (Driving Record) to the above companies for purpose of investigation as required by Sections 391.29, 291.25 of the Federal Motor Carrier Safety Regulations. You are released from any and all liability which may result from furnishing such information. Applicant's Initials: Date: Rev: BRL 01/02/2014
APPLICANT'S NAME: SOCIAL SECURITY NUMBER REQUEST FOR CHECK OF DRIVING RECORD I hereby authorized the release of Motor Vehicle Record (Driving Record) to the above companies for purpose of investigation as required by Sections 391.29, 291.25 of the Federal Motor Carrier Safety Regulations. You are released from any and all liability which may result from furnishing such information. Applicant's Initials: Date: Rev: BRL 01/02/2014
APPLICANT'S NAME: SOCIAL SECURITY NUMBER: MOTOR VEHICLE DRIVER'S CERTIFICATION OF COMPLIANCE WITH DRIVER LICENSE REQUIREMENTS Parts 383 and 391 of the Federal Motor Carrier Safety Regulations require that all drivers comply with the following: 1. POSSESS ONLY MOTOR VEHICLE OPERATOR'S LICENSE: If you have more than one license, keep the license from your state of residence and return additional licenses to the states that issued them. DESTROYING a license does not close the record in the state that issued it; you must notify the state. If multiple license has been lost, stolen, or destroyed, close your records by notifying the state of issuance that no longer want to be licensed by that state. 2. NOTIFICATION OF LICENSE SUSPENSION, REVOCATION OR CANCELLATION: Sections 391.15(b) (2) and 383.33 of the Federal Motor Carrier Safety Regulation require that you notify the motor carrier you are driving for by THE NEXT BUSINESS DAY of any revocation or suspension of your driver's license. In addition, Section 383.1 requires that any time you violate a state or local traffic law (other than Parking), you must report it (in writing) within 30 days to: 1) the motor carrier you are driving for, and 2) the state that issued your license (if the violation occurs in a state other than the one which issued your license. The following license is the ONLY one I possess: Driver License No. State: Exp. Date: Driver's Name: (Printed) Driver's Signature: Date: Rev: BRL 01/02/2014
APPLICANT'S NAME: SOCIAL SECURITY NUMBER: POLICY AND REGULATION RECEIPT I have received the Federal Motor Carrier Safety Regulations Pocketbook. In addition, I agree to familiarize myself with the Federal Motor Carrier Safety Regulations (FMCSR) of the U.S. Department of Transportation, Parts 40, 382, 383, 390-397, 399 Subchapter B, Chapter 3, Title 49 of the Code of Federal Regulations as contained therein. Applicant's Initials': Rev: BRL 01/02/2014
APPLICANT'S NAME: SOCIAL SECURITY NUMBER: DRUG, ALCOHOL AND SUBSTANCE ABUSE POLICY AND PROGRAM I have received the Drug, Alcohol and Substance Abuse Policy and Program for Blackrock Logistics, Inc and its other affiliated companies, and understand that compliance with such is required and that if I violate the Policy or refuse to cooperate with testing procedures as stated in the Policy, I am subject to disciplinary action, up to, and including termination. Applicant's Initials: Rev: BRL 01/02/2014
MOTOR VEHICLE DRIVER'S CERTIFICATION OF VIOLATIONS/ANNUAL REVIEW OF DRIVING RECORD MOTOR CARRIER INSTRUCTIONS: Each motor carrier shall at least once every 12 months, require each driver it employs to prepare and furnish it with a list of all violations of motor vehicle traffic laws and ordinances (other than violations involving only parking) of which the driver has been convicted, or on account of which he/she has forfeited bond or collateral during the preceding 12 months (Section 391.27). Drivers who have provided information required by Section 383.31 need not repeat that information on this form. DRIVER REQUIREMENTS: Each driver shall furnish the list as required by the motor carrier above. If the driver has not been convicted of, or forfeited bond or collateral on account of any violation which must be listed, he/she shall so certify (Section 391.27). COMPLETED BY DRIVER - CERTIFICATION OF VIOLATIONS DATE OF EMPLOYMENT HOME TERMINAL (CITY, STATE) DRIVER'S LICENSE STATE EXPIRATION DATE I certify that the following is a true and complete list of traffic violations (other than parking violations) for which I have been convicted or forfeited bond or collateral during the past 12 months. DATE OFFENSE LOCATION TYPE OF VEHICLE OPERATED (If you have had no violations, check the following box - None.) If no violations are listed above, I certify that I have not been convicted or forfeited bond or collateral on account of any violation (other than those I have provided under Part 383) required to be listed during the past 12 months. (Driver's signature) (Date) COMPLETED BY MOTOR CARRIER - ANNUAL REVIEW OF DRIVING RECORD 391.25(b)(2)The motor carrier must consider the driver's accident record and any evidence that the driver has violated laws governing the operation of motor vehicles, and must give great weight to violations, such as speeding, reckless driving, and operating while under the influence of alcohol or drugs, that indicate that the driver has exhibited a disregard for the safety of the public. A careful review of the driver's record has been made in accordance with Part 391.25 and he/she has been found to: [ ] meet the minimum requirements for safe driving [ ] not meet the minimum requirements of safe driving [ ] be disqualified to drive a commercial motor vehicle pursuant to Part 391.15. Action taken with driver: (Reviewed by: Signature) (Title) (Date).
www.cdtaonline.com 888-908-2382 DOT/FMCSA Previous Employee Investigations & Inquiries - - First Name Middle Name Last Name Social Security Number Current Address City State Zip / / Company Name Driver s License Number State Date of Birth Applicant Telephone Number I hereby authorize the above named company to release any and all information to concerning my performance, conduct, accident record and all required DOT drug and alcohol related information while previously employed as a commercial motor vehicle operator in the previous 3 years from the date of this form as specified and required by the Federal Motor Carrier Safety Regulations, Part 391.23 investigation and inquiries. In connection with, and for the duration of, my employment (including contract for services) with you, I understand that investigative background inquires are to be made on myself including consumer, driving, and other reports. This information will, in whole or in part, be obtained from CDTA, A Part of National Compliance Solutions Inc., 1011 Camino Del Rio South, Suite 200, San Diego, CA 888. 908.2382. These reports will include information as to my work habits, performance and experience along with reasons for termination of past employment from previous employers. Further, I understand that you will be requesting information from various federal, state and other agencies which maintain records concerning my past activities relating to my driving, credit, civil and other experiences as well as notable criminal activity & claims involving me in the files of insurance companies. This release may also be used to obtain worker s compensation and education records. By signing below, I also acknowledge that I have read and understand the summary of my rights under The Fair Credit Reporting Act Pub. L. 111-203, H.R. 4173. APPLICANT S SIGNATURE: Date: Previous Company Name: Mailing Address: City: State Zip Supervisors Name: Period of Employment: FROM / TO / MO. YR. MO. YR. Is employment record with your company correct? Why did applicant leave? If Company policy allowed, would you rehire? Did he have custody of money or valuables? Qualified in what equipment? How many total accidents? Driver s license ever revoked or suspended? Telephone Number: How many FMCSA defined recordable accidents? Position Held: TO FORMER EMPLOYER: Please give the following information about this applicant. It will be held in strict confidence. Description Excellent Good Fair Poor Supervision Comments Quality of Work Cooperation with Others Safety Habits Driving Skills Attendance Record Yes No DOT/FMCSA Previous Employer 3-year Drug and Alcohol Investigation and Inquiry Did the employee have an alcohol test with results greater than 0.04 BAC? Did the employee have a verified positive test result? Did this employee refuse to be tested? Did the employee have any other violation of the DOT/FMCSR drug and alcohol testing regulations? Did the employee report any drug and alcohol rule violations to you? If you answered yes to any of the above items, did the employee complete an SAP program and return to duty test? *** If yes, please send the employee s SAP reports, return to duty documentation and any and all follow-up test information or records. This company did not have a DOT drug/alcohol program during this period. The information requested is required by Part 391.23 for the U.S. Department of Transportation Motor Carrier Safety Regulations. Signed: Position: Date : Print Name/ Sign Name Notice to California Applicants: Under Section 1786.22 of the California Civil Code, you have the right to request from CDTA, upon proper identification, the nature and substance of all information in its files on you, including the sources of information, and the recipients of any reports on you which CDTA has previously furnished within the two-year period preceding your request. You may view the file maintained on you by CDTA during normal business hours. You may also obtain a copy of this file upon submitting proper identification and paying the costs of duplication services. Upon making a written request, you may receive a summary report via telephone. California, Minnesota & Oklahoma Applicants only: Please check here to have a copy of your consumer report sent directly to you. Minnesota & Oklahoma applicants receive a copy direct from CDTA. California applicants may receive a copy from either the prospective employer or CDTA. Date Sent/Initial: 2 nd Request Date/Initial 3 rd Request Date Initial