Driver s Application for Employment In compliance with the Federal and State equal employment opportunity laws, qualified applicants are considered for all positions without regards to race, color, religion, sex, national origin, age, marital status, veteran status, non-job related disability, or any other protected group status. Date of Application Company Name: Gemcap Trucking, Inc. Date of Birth: Drivers Name: Social Security # - - Current Address: City State Zip Main Contact Number: Alternate Contact Number: Email Address if applicable: List your addresses of residency for the past 3 years. Previous Address How Long? City State Zip Yrs/Months How Long? City State Zip Yrs/Months How Long? City State Zip Yrs/Months Do you have legal rights to work in United States of America? Have you ever worked for this company before? Dates: From to Where? Position: Reason for Leaving: Are you employed now: If not, how long since last employment? Have you ever been convicted of a felony? If yes please explain why: 1
Is there any reason you may not be able to perform the functions of the job for which you have applied for? Yes No If yes, please explain why: Employment History All driver applicants to drive in interstate commerce must provide the following information relating to all employers during the past 3 years. List complete mailing addresses, street number, city, state and zip code. Applicants to drive a commercial motor vehicle in interstate or intrastate commerce shall also provide an additional 7 years of information on those employers for whom the applicant operated a commercial vehicle. Name From Address To City State Zip Reason for Leaving Contact Person Phone Did you drive a vehicle requiring a CDL? Name From Address To City State Zip Reason for Leaving Contact Person Phone Did you drive a vehicle requiring a CDL? Name From Address To City State Zip Reason for Leaving Contact Person Phone Did you drive a vehicle requiring a CDL? Name From Address To City State Zip Reason for Leaving Contact Person Phone Did you drive a vehicle requiring a CDL? Name From Address To City State Zip Reason for Leaving Contact Person Phone Did you drive a vehicle requiring a CDL? Name From Address To City State Zip Reason for Leaving Contact Person Phone Did you drive a vehicle requiring a CDL? 2
Accident Record Below please list any accidents for the past 3 years. If no accidents, please write N/A. Date of Accident Nature of Accident Fatalities Injuries Last Accident: Previous: Previous: Previous: Previous: Previous: Traffic Convictions and Forfeitures for the past 3 years (other than parking violations). If none, write N/A (non applicable) Location Date Charge Penalty Education List all the drivers licenses you have obtained as a CDL driver and all the endorsements you hold. State License # Type Expiration Date Have you ever been denied a license, permit or privilege to operate a motor vehicle? Has any license, permit or privilege ever been suspended or revoked? If you answered yes to any of the above questions, please explain below: 3
Driving Experience and Qualifications If non please indicate N/A (non applicable) Class Equipment Type of Equipment Dates Approximate no. of miles (Van, Tank, Flat, ect.) (Total) Straight Truck Tractor and Semi-Trailer Tractor Two Trailers Motor Coach-Bus Other Motor Vehicle Drivers Certification of Violations 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 no violations are listed above, I certify that I have not been convicted or forfeited bond or collateral on account of any violation required to be listed during the past 12 months. (Date of Certification) (Motor Carriers Name) (Driver s Signature) (Motor Carriers Address) (Reviewed by Signature) (Title) List state operated within the last 5 years: List special courses or trainings that will help you as a driver: 4
Which safe driving awards do you hold and from whom: Show any trucking, transportation, or other experience that may help in your job for this company: List courses and trainings other than shown elsewhere in the application: List special equipment or technical materials you can work with: To Be Read and Signed by the Applicant This certifies that this application was completed by myself, and that all entries on it and information in it are true and to the best of my knowledge. I authorize Gemcap Trucking, Inc. to make such investigation and inquiries of my personal, employment, financial or medical history and other related matters as may be necessary in arriving at an employment decision. (Generally, inquiries regarding medical history will be made only if and after conditional offer of employment has been extended.) I hereby release employers, schools, healthcare providers and other from all liability in responding to inquiries and releasing information in connection with my application. In the event of my employment, I understand that false or misleading information given in my application or interview may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the company. Date of Application Signature of Applicant 5
Fair Credit Reporting Act Disclosure Statement Regulation Regulacion de Informacion In accordance with the provisions of Section 604(b) (2) (a) 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 maybe 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. De acuerdo con las reglas de la sección 604(b) (2) (a) de la ley de Crédito al Consumidor, ley Publica 91-508, y emendada por la Ley de Reportes de Crédito del Consumidor del 1996 (Titulo II subtitulo d Capitulo I Ley Publica 104-208), usted está siendo informado que la verificación por parte nuestra de sus resultados de drogas y alcohol anteriores a hoy, también como su historial de manejo es solamente con fines de su aplicación para trabajar con la compañía de transporte mencionada en este documento. Estas verificaciones son requeridas por las Secciones 382, 413, 391.23, y 391.25 de las Regulaciones Federales en Seguridad para las Compañías de Transporte. Company Name: Applicants Name: Applicants Social Security Number: Applicants Signature: 6
DOT Mandated Preventive Maintenance Program for Owner Operators and Drivers I, the undersigned understand that as an owner operator, or driver operating under an owner operator must comply with preventive maintance program mandated by the DOT and the carrier s insurance company. 1. I understand that on-going preventive maintenance must be performed on my power unit and trailer on a continuous basis. This included not limited to; oil changes, lubrication, tire care, brake services, filter changes, and etc. 2. I understand that once service has been completed, a copy of such service as well as a copy of any material purchased for such service must be provided to the carrier. 3. I understand that failing to comply with this mandated DOT Regulation can be ground for terminating services with the carrier. Owner Operator/ Driver Signature Carrier Name Date Programa de Mantenimiento Preventivo del DOT Yo entiendo como dueño operador, o chofer operador bajo un dueño operador que tengo que cumplir con el Programa de Mantenimiento Preventivo por las Regulaciones del DOT, al igual que la compañía de seguros. 1. Yo entiendo que este programa tiene que ser seguido de una manera continua, y que aplica al camión y al remolque. Este programa de mantenimiento incluye; cambio de aceite, lubricación, llantas, frenos, filtros, ect. 2. Yo entiendo que una vez que el mantenimiento o reparación sea completado, tengo que entregar copia de los recibos a la compañía. 3. Yo entiendo que si no cumplo con este requerimiento puede ser motivo para que la compañía de por terminado mis servicios. Dueno Operador/Chofer Firma Compania Fecha 7
Motor Vehicle Driver s Certification of Violations/Annual Review of Driving Record (Request for Check of Driving Record) I hereby authorize you Gemcap Trucking, Inc. for purposes of investigations required by Sections 391.23 and 391.25 of the Federal Motor Carrier Safety Regulations. You are released from any and all liability which may result from furnishing such information. In accordance with provisions of section 604 and 607 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). I hereby certify that: 1. The consumer (applicant) has authorized in writing procurement of this report; 2. The consumer (applicant) has been informed in a separate written disclosure that a consumer report may be obtained for employment. 3. The information requested below will be used for a permissible purpose (I.e information for employment purposes) and will be used for no other purpose; 4. The information being obtained will not be used in violation of any federal or state equal opportunity law or regulation; 5. Before taking adverse action based in whole or in part on the report the consumer (applicant) will receive a copy requested report and the summary of consumer rights as provided with the consumer reporting agency. I also hereby certify that this report request and the applicants release notice meet the definition of permissible uses of state motor vehicle records under the provisions of the Driver s Privacy Protection Act of 1994 (Public Law 103-322, Title XXX, Section 300002(a)). Motor Carrier Instructions: Each motor carrier shall at least once every 12 months, require each driver and employees to prepare and furnish it with a list of all violations of motor vehicle traffic laws and ordinance (other than violations involving only parking) of which the driver has been convicted, or an account of which he/she has forfeited bond or collateral during proceeding 12 months (Section 391.27). Drivers who have provided information required by Section 383.31 need not repeat that information on this form. Drivers Requirement: 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 must be listed, he/she shall so certify (Section 391.27). Completed By Driver- Certification Violation Name of Driver (Print) Social Security Number Date of Employment Home Terminal: City and State Driver's License # State Expiration Date I certify that the following is a true and complete list of traffic violations required to be listed (other than those I have provided under Part 383) for which I have been convicted or forfeited bond or collateral during the past 12 months. If you have had no violations, please write N/A for non applicable: 8
Date Offense Location Type of Vehicle 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. Date of Certification Drivers Signature Completed by Motor Carrier-Annual Review of Driving Record Motor Carrier Instructions: Review the Certification of Violations listed above and other information described in Section 391.25 of the Federal Motor Carrier Safety Regulations. Complete the information requested below. I have hereby reviewed the driving record of the above named driver in accordance with Section 391.25 and find that he/she (check one) Meet minimum requirements for safe driving Section 391.15 Is disqualified to drive a motor vehicle pursuant to gthenfn[fg Does not adequately meet satisfactory safe driving performance Action taken with Driver: Reviewed By: Signature Printed Name Date Title Motor Carrier Name Motor Carrier Address 9
Motor Vehicle Driver s Certificate of Compliance Motor Carrier Instructions: The requirements in Part 383 apply to every driver who operates in intrastate, interstate, or foreign commerce and operates a vehicle weighing 26,001 pounds or more, can transport more than 15 people or transports hazardous material that requires placards. The requirements in Part 931 apply every driver who operates a vehicle weighing 10,001 pound or more, can transport more than 15 people, or transports hazardous material that requires placards. Driver Requirements: Part 383 and 391 of the Federal Motor Carrier Safety Regulation contain some requirements that you as a driver must comply with. These requirements are in effect as of July 1, 1987. They are as follow: 1. POSSESS ONLY ONE LICENSE: You, as a commercial vehicle driver, may not possess more than one motor vehicle operator s license. If you have more than one license, keep the license from your state of residence and return the 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 a multiple license has been lost, stolen or destroyed, close your record by notifying the state of issuance that no longer wants 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 Regulations require that you notify your employer the next business day of any revocation or suspension of your driver s license. In addition, Section 383.31 requires that anytime you violate a state or local traffic law (other than parking), you must report it within 30days to: 1) your employing motor carrier, and 2) the state that issued your license (if the violations occurs in a state other than the one which issued your driver s license). The notification to both the employer and state must be in writing. The following license is the only I will posses: Driver s License No: State: Expiration Date: Driver Certification: I certify that I have read and understood the above requirements Driver s Name (Print) Driver s Signature: Company Name: Date of Application: 10
Driver Statement of On-Duty Hours (For Newly Hired Drivers) Instructions: Motor carriers when using a driver for the first time shall obtain from the driver a signed statement giving the total time on-duty during the immediately preceding 7 days and time at which such driver was last relieved from duty prior to beginning work for such carrier. Rule 395.8 (j) (2) Federal Motor Carrier Safety Regulations. Note: Hours for any compensated work during the preceding 7 days, including work for a non-motor carrier entity, must be recorded on this form. Driver Name (Print): Social Security Number: Drivers License Number: State Class Endorsement Restrictions: Type of License: Issuing State: DAY 1- Yesterday 2 3 4 5 6 7 DATE Hours Worked Total Hrs: I hereby certify that the information given above is correct to the best of my knowledge and belief, and that I was last relieved from work at: A.M. P.M. On: Day Month Year Drivers Signature Date Signed 11
Driver Certification for Other Compensated Work INSTRUCTIONS: When employed by a motor carrier, a driver must report to the carrier all on-duty time including time of working for other employers. The definition of on-duty time is found in Section 395.2 paragraphs 8 and 0 of the Federal Motor Carrier Safety Regulations includes time performing any other work in capacity of, or in the employ or service of, a common, contract or private motor carrier, also performing any compensated work for any non motor carrier entity. Are you currently working for another employer? At this time do you intend to work for another employer while still employed by this company? I hereby certify that the information given above is true and I understand that once I become employed with this company, if I begin working for any additional employer (s) for compensation that I must inform this company immediately of such employment activity. Drivers Signature Date Company Representative Date 12
Hours of Service/ Log Disciplinary Policy GEMCAP Trucking, Inc. has implemented a ZERO TOLERANCE policy. Gemcap Trucking, Inc WILL NOT tolerate any employee driver or independent contractor who either operates a motor vehicle, accepts dispatch, dispatches or coordinates any movement that would cause the maximum hours of service standards as set forth by the Federal Motor Carrier Safety Administration (U.S.D.O.T.) to be exceeded. 1 st Offense: $200.00 Fine and a Written Warning 2 nd Offense $350 Fine and Dismissal Involvement in ANY accident or incident where hours of service has been exceeded and driver cited: 1 st Offense: Termination Citation for Hours of Service or Log Not Current 1 st Offense: $200.00 Fine and a Written Warning 2 nd Offense $350.00 Fine and Dismissal Log Book Form Manner All log books must be printed or written legibly and must be turned in when you arrive to base from a trip, along with all other trip documents. Failure to complete log book per CFR 49 will result in the below sanctions. Average speed can be no more than 5 miles per hour under the posted speed limit for any segment or between any 2 points. Fuel stops, loading, unloading, pre-trip inspections, and post-trip inspections must be logged on the date and time that actually occurred. Logging these events is a must, not an option. 1 st Offense: $200.00 Fine and a Written Warning 2 nd Offense $350.00 Fine and Dismissal 1 st Offense: Termination Falsification of Log Falsification OBC Entries 1 st Offense: Termination Employee/Driver Sign Date Print Your Name 13