App – CDL Driver App

Driver Applicant Drug and Alcohol Pre-Employment Statement

CFR Part 40.25(j) requires the employer to ask the applicant, whether he or she has tested positive, or refused to test, on any pre-employment drug or alcohol test administered by an employer to which the employee applied for, but did not obtain, safety-sensitive transportation covered by DOT agency drug and alcohol rules during the past two years. If the potential employee admits that he or she had a positive test or refusal to test, we must not use the employee to perform a safety-sensitive function, until and unless the potential employee provides documentation of successful completion of the return-to-duty process. (See Section 40.25(b)(5) and (e).

As an applicant, applying to perform safety-sensitive functions for our company, you are required by CFR Part 40.25(j) to respond to the following questions.

Controlled Substance & Alcohol Testing Information Acknowledgement & Consent Form

As a condition of employment with {carrier:276}, Commercial Motor Vehicle (CMV) Driver Applicants must submit to a pre-employment controlled substances test as required by the Federal Motor Carrier Safety Regulations (FMCSR) Section 381.301.

A motor carrier must receive verified negative test results for the applicant driver for the applicant to be eligible for employment.

If you are hired, you will be subject to laws requiring additional controlled substances and alcohol testing on you under numerous situations including, but not limited to, the following:
• Post-Accident - Section 382.303
• Random - Section 382.305
• Reasonable Suspicion - Section 382.307
• Return to Duty - Section 382.309
• Follow-up - Section 382.311

A driver who tests positive for a controlled substance(s) and/or alcohol test will be immediately removed from a safety-sensitive position as required by Part 382 of the FMCSR. Federal law prohibits a Driver from returning to a safety-sensitive position for any motor carrier until and unless the Driver completes the Substance Abuse Professionals (SAP) evaluation, referral, and educational/treatment process, as described in FMCSR Part 40, Subpart 0.

{carrier:276} will provide a list of substance abuse professionals.

As a Commercial Motor Vehicle (CMV) Driver, I understand that per the Federal Motor Carrier Safety Regulations (FMCSRs) Part 391.21, the following information will be requested from all previous Employers for which I operated a CMV, subject to the FMCSR Parts 390 and/or 40, 382 & 383, within the past three years, from date shown below. I also acknowledge that this information will be used in determining my eligibility to be hired, that I have the right to review this information and rebut any errors in these statements from my prior employers, as described in the FMCSR Part 391.23.

I, {Name (First):13.3} {Name (Last):13.6}, on this date hereby authorize {carrier:276} to release all records of employment, including assessments of my job performance, ability and fitness (including dates of any and all alcohol or drug tests, those confirmed results and/or my refusal to submit to any alcohol or drug tests and any rehabilitation completion under direction of (SAP/MRO) to each and every company (or their authorized agents) which may request such information in connection with my application for employment with said company. I hereby release {carrier:276} and its employees, officers, directors, and agents from any and all liability of any type as a result of providing information to the above-mentioned person and/or company.

APPLICANT AUTHORIZATION CONSENT FOR RELEASE OF INFORMATION

DRIVER'S RIGHTS PERTAINING TO RELEASE OF DRIVER INFORMATION UNDER REGULATION 391.23

Motor carriers have the responsibility to make the following investigations and inquiries with respect to each driver employed, other than a person who has been a regularly employed driver of the motor carrier for a continuous period which began before January 1, 1971.
A.1) An inquiry into the driver's driving record during the preceding three years to the appropriate agency of every State in which the driver held a motor vehicle operator's license or permit during those three years; and
A.2) An investigation of the driver's employment record during the preceding three years.
B) A copy of the driver record(s) obtained in response to the inquiry or inquiries to each State driver record agency as required must be placed in the Driver Qualification File within 30 days to the date the driver's employment begins and be retained in compliance with 391.51.
C) Replies to the investigations of the driver's safety performance history must be place in the Driver Investigation History File within 30 days of the date the driver's employment begins. This goes into effect after October 29, 2004.
D) Prospective motor carrier must investigate the information from all previous employers if the applicant that employed the driver to operate a CMV within the previous three years. This information must cover general driver identification and employment verification information, and any accidents the previous employer may wish to provide.
E) Prospective motor carrier must investigate the information from all previous DOT regulated employers that employed the driver with the previous three years from the date of the employment application in a safety-sensitive function that required alcohol and controlled substance testing specified by 49 CFR Part 40.

Drivers have the following rights:
1. The right to review information provided by previous employers.
2. The right to have errors in the information corrected by the previous employer and for that previous employer to re-send the corrected information to the prospected employer.
3. The right to have a rebuttal statement attached to the alleged erroneous information, if the previous employer and the driver cannot agree on the accuracy of the information.

Drivers who wish to review previous employer-provided investigative information must submit a written request to the prospective employer when applying or as late as 30 days after employed or being notified of denial of employment. The prospective employer must this information to the applicant within five business days of receiving the written request. If the driver has not arranged to pick up or receive the requested records within 30 days of the prospective employer making them available, the prospective motor carrier may consider the driver to have waived his/her request to review the records.

Drivers wishing to request correction of erroneous information in records must send the request for the correction to the previous employer that provided the records. After October 29, 2004, the previous employer must either correct and forward the information to the prospective motor carrier employer or notify the driver within 15 days of receiving the driver's request to correct the data that it does not agree to correct the data. Drivers wishing to rebut information in records must send the rebuttal to the previous employer with instruction to include the rebuttal in the driver's Safety Performance History.

I acknowledge that I have read and understand the contents of this document

{carrier:276} requires as a condition of employment, and/or continued employment, that all applicants consent to and authorize a verification of the information submitted on their applications or resume.

Please read this statement carefully.

I, {Name (First):13.3} {Name (Last):13.6}, do hereby certify that the information provided by me for the purpose of employment is true and complete to the best of my knowledge. I understand that if J am employed any false statement will be considered as a cause for possible dismissal.

This release and authorization acknowledge that this Company may now, or at any time while I am employed, conduct a verification of my education. employment history, social security and, credit history, motor vehicle records, to contact a personal references, and to receive any criminal history record information pertaining to me which may be in the files of any Federal, State, or Local criminal justice agency in any state, and/or other information as deemed necessary to fulfill the job requirements. Also, if an offer of employment has been made. I authorize review of my worker’s compensation claim history.

I authorize {carrier:276} and any of its agents and/or employees to disclose orally and in writing the results of the verification process to the designated authorized representatives of this Company. The results will be used to determine employment eligibility under this Company’s employment policies.

I have read and understand this release and consent, and I authorize the background verification. I authorize the person, schools, current and former employers, and other organizations and agencies to provide {carrier:276} with all information that may be requested, and hereby release all of the persons and agencies providing such information from any and all claims and damages connected with their release of any requested information. I agree that any copy of this document is as valid as the original.

I do hereby agree to forever release and discharge this Company, its agents, {carrier:276} and their associates to the full extent permitted by law from any claims damages, losses, liabilities, costs, and expenses, or any other charge or complaint filed with any agency arising from the retrieving and reporting of information. According to the Federal Fair Credit Reporting Act, I am entitled to know if employment was denied information obtained by my prospective employer, and to receive, upon written request, ·a disclosure of the public record information and of the nature and scope of the investigative report.

It is agreed and understood that any misrepresentation given on this application shall be considered an act of dishonesty. It is agreed and understood that the motor carrier or his agents may investigate the applicant’s background to ascertain any and all information of concern to applicant’s record, wether same is of record or not, and applicant releases employers and persons named herein from all liability for any damages on account of his furnishing such information. It is also agreed and understood that under the Fair Credit Reporting Act, Public Law 91-508; I have been told that this investigation may include an investigating Consumer Report, including information regarding my character, general reputation, personal characteristics, and mode of living. I agree to furnish such additional information and complete such examinations as may be required to complete my application file. It is agreed and understood that this Application for Qualification in no way obligates the motor carrier to employ or hire the applicant. It is agreed and understood that if qualified and hired, I may be on a probationary period during which time I may be disqualified without recourse. This certifies 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.

Signature

REQUEST FOR DRIVER'S SAFETY PERFORMANCE HISTORY INFORMATION FROM DOT REGULATED EMPLOYER(S)

SECTION I: DRUG & ALCOHOL INFORMATION

Past Employer to Complete

Please provide the following Drug and Alcohol Information as required by FMCSR Part 391.23 & 4025.

If there is no Drug and Alcohol Information available for {Name (First):13.3} {Name (Last):13.6}, please check here. ▢

1. Any alcohol with a result of 0.04 or higher alcohol concentration? ▢ YES ▢ NO

2. Any verified positive drug test? ▢ YES ▢ NO

3. Any refusals to be tested (including verified adulterated or substituted drug test results)? ▢ YES ▢ NO

4. Any other violations of DOT agency drug & alcohol testing regulations (Part 382 or Part 40)? ▢ YES ▢ NO

5. If this Driver did successfully complete a SAP rehabilitation referral and remained in your employ
did he/she have any subsequent violations for; an Alcohol test result of 0.04 or greater, a verified
positive drug test or a refusal to test (including a verified adulterated/substituted drug test result?) ▢ YES ▢ NO

6. If yes to any of the above questions, please provide documentation of successful completion of a SAP evaluation, prescribed treatment and return-to-duty requirements (including follow-up tests) if they remained in your employ.*

If this information is not available from the previous. employer, you: as a prospective employer, must get this Information from the Driver/Applicant.

Drug and Alcohol information needs to be kept in a separate Personnel and/or Confidential file.

SECTION II: ACCIDENT INFORMATION

Please provide the following information as required by 391.23(d) (I)(2) on any accidents, as defined by 390.5 and/or from your Accident Register (FMCSR 391.15) which the above named Driver/Applicant was involved within the past three years while under your employment. Previous employers may include additional detailed information on minor accidents/incidents at their discretion.

If there is no accident information available for {Name (First):13.3} {Name (Last):13.6}, please check here. ▢

	Date	Location Indicate City/Town & State	Any Vehicles Towed?	HazMat Spill	Number of Fatalities	Number of Injuries

1) ______________________________________________________________________________________________________________________________

2) ______________________________________________________________________________________________________________________________

3) ______________________________________________________________________________________________________________________________

SECTION III: WORK HISTORY INFORMATION

{Name (First):13.3} {Name (Last):13.6} was employed as a _____________________________________.
If employed as a driver, what equipment did they operate?
▢ Straight Trucks ▢ Tractor Trailer ▢ Doubles ▢ Triples ▢ Other
Explain: _________________________________________________________________________________________________________________

As what type of driver or employee was {Name (First):13.3} {Name (Last):13.6} was classified?
▢ Company Driver ▢ Contractor's Driver ▢ Contractor ▢ Other
Explain: _________________________________________________________________________________________________________________
General Area Traveled: ________________________________________________________________________________________________
Commodities Transported: ____________________________________________________________________________________________

While under your employ was {Name (First):13.3} {Name (Last):13.6} bonded? ▢ YES ▢ NO

While under your employ was {Name (First):13.3} {Name (Last):13.6} convicted of any traffic violations? ▢ YES ▢ NO If yes, please list all, including date and type:
___________________________________________________________________________________________________

While under your employ was {Name (First):13.3} {Name (Last):13.6}'s license suspended, revoked or denied? ▢ YES ▢ NO
Explain: _________________________________________________________________________________________________________________

Would you re-employ {Name (First):13.3} {Name (Last):13.6}? ▢ YES ▢ NO ▢ Upon Review
Explain: _________________________________________________________________________________________________________________

Reason for leaving: _____________________________________________________________________________________________________

Previous Employer Representative Supplying Information
____________________________________________________ ________________________________________________
Printed Name Title

____________________________________________________ ________________________________________________
Signature Date

Note: Failure to furnish information as required by 49C FR 382.405 and 382.413 is a violation of the U.S. Department of Transportation. Federal Motor Carrier Safety Administration. Failure to provide this information may result in a fine and/or civil liability.

REQUEST FOR DRIVER'S SAFETY PERFORMANCE HISTORY INFORMATION FROM DOT REGULATED EMPLOYER(S)

1st Past Employer Carrier
{employer-name-PE1:47}

As a Commercial Motor Vehicle (CMV) Driver, I, {Name (First):13.3} {Name (Last):13.6},understand that per the Federal Motor Carrier Safety Regulations (FMCSRs) Part 391.21, the following information wIll be requested from all previous Employers for which I operated a CMV, subject to the FMCSR Parts 390 and/or 40, 382 & 383, within the past three years, from date shown below. I also acknowledge that this information will be used in determining my eligibility to be hired, that I have the right to review this information and rebut any errors in these statements from my prior employers, as described in the FMCSR Part 391.23.

I, {Name (First):13.3} {Name (Last):13.6}, hereby authorize this Company to release all records of employment, including assessments of job performance, ability and fitness including dates of any and all alcohol or drug tests, those confirmed results and/or my refusal to submit to any alcohol or drug test and any rehabilitation completion under direction of (SAP/MOR) to each and every company (or their authorized agents) which may request such information in connection with my application for employment with Company. I hereby release the company and its employees, officers, directors and agents from any and all liability of any type as a result of providing information to the above-mentioned person and/or company.

Previous Employer Name
{Name (First):13.3} {Name (Last):13.6}

Contact Person

________________________________________

Mailing Address
{home-address (Street Address):313.1} {home-address (Address Line 2):313.2}
{home-address (City):313.3}, {home-address (State / Province):313.4}{home-address (ZIP / Postal Code):313.5}

Phone Number
{phone-number:14}

Fax Number

________________________________________

Dates of Employ
{dates-PE1:52}

Signature - 1st Past Employer

REQUEST FOR DRIVER'S SAFETY PERFORMANCE HISTORY INFORMATION FROM DOT REGULATED EMPLOYER(S)

2nd Past Employer Carrier
{employer-name-PE2:400}

As a Commercial Motor Vehicle (CMV) Driver, I, {Name (First):13.3} {Name (Last):13.6},understand that per the Federal Motor Carrier Safety Regulations (FMCSRs) Part 391.21, the following information wIll be requested from all previous Employers for which I operated a CMV, subject to the FMCSR Parts 390 and/or 40, 382 & 383, within the past three years, from date shown below. I also acknowledge that this information will be used in determining my eligibility to be hired, that I have the right to review this information and rebut any errors in these statements from my prior employers, as described in the FMCSR Part 391.23.

I, {Name (First):13.3} {Name (Last):13.6}, hereby authorize this Company to release all records of employment, including assessments of job performance, ability and fitness including dates of any and all alcohol or drug tests, those confirmed results and/or my refusal to submit to any alcohol or drug test and any rehabilitation completion under direction of (SAP/MOR) to each and every company (or their authorized agents) which may request such information in connection with my application for employment with Company. I hereby release the company and its employees, officers, directors and agents from any and all liability of any type as a result of providing information to the above-mentioned person and/or company.

Previous Employer Name
{employer-name-PE2:400}

Contact Person

________________________________________

Mailing Address
{home-address (Street Address):313.1} {home-address (Address Line 2):313.2}
{home-address (City):313.3}, {home-address (State / Province):313.4}{home-address (ZIP / Postal Code):313.5}

Phone Number
{phone-number:14}

Fax Number

________________________________________

Dates of Employ
{dates-PE2:427}

Signature - 2nd Past Employer

REQUEST FOR DRIVER'S SAFETY PERFORMANCE HISTORY INFORMATION FROM DOT REGULATED EMPLOYER(S)

3rd Past Employer Carrier
{employer-name-PE3:403}

As a Commercial Motor Vehicle (CMV) Driver, I, {Name (First):13.3} {Name (Last):13.6},understand that per the Federal Motor Carrier Safety Regulations (FMCSRs) Part 391.21, the following information wIll be requested from all previous Employers for which I operated a CMV, subject to the FMCSR Parts 390 and/or 40, 382 & 383, within the past three years, from date shown below. I also acknowledge that this information will be used in determining my eligibility to be hired, that I have the right to review this information and rebut any errors in these statements from my prior employers, as described in the FMCSR Part 391.23.

I, {Name (First):13.3} {Name (Last):13.6}, hereby authorize this Company to release all records of employment, including assessments of job performance, ability and fitness including dates of any and all alcohol or drug tests, those confirmed results and/or my refusal to submit to any alcohol or drug test and any rehabilitation completion under direction of (SAP/MOR) to each and every company (or their authorized agents) which may request such information in connection with my application for employment with Company. I hereby release the company and its employees, officers, directors and agents from any and all liability of any type as a result of providing information to the above-mentioned person and/or company.

Previous Employer Name
{employer-name-PE3:403}

Contact Person

________________________________________

Mailing Address
{home-address (Street Address):313.1} {home-address (Address Line 2):313.2}
{home-address (City):313.3}, {home-address (State / Province):313.4}{home-address (ZIP / Postal Code):313.5}

Phone Number
{phone-number:14}

Fax Number

________________________________________

Dates of Employ
{dates-PE3:426}

Signature - 3rd Past Employer

REQUEST FOR DRIVER'S SAFETY PERFORMANCE HISTORY INFORMATION FROM DOT REGULATED EMPLOYER(S)

4th Past Employer Carrier
{employer-name-PE4:402}

As a Commercial Motor Vehicle (CMV) Driver, I, {Name (First):13.3} {Name (Last):13.6},understand that per the Federal Motor Carrier Safety Regulations (FMCSRs) Part 391.21, the following information wIll be requested from all previous Employers for which I operated a CMV, subject to the FMCSR Parts 390 and/or 40, 382 & 383, within the past three years, from date shown below. I also acknowledge that this information will be used in determining my eligibility to be hired, that I have the right to review this information and rebut any errors in these statements from my prior employers, as described in the FMCSR Part 391.23.

I, {Name (First):13.3} {Name (Last):13.6}, hereby authorize this Company to release all records of employment, including assessments of job performance, ability and fitness including dates of any and all alcohol or drug tests, those confirmed results and/or my refusal to submit to any alcohol or drug test and any rehabilitation completion under direction of (SAP/MOR) to each and every company (or their authorized agents) which may request such information in connection with my application for employment with Company. I hereby release the company and its employees, officers, directors and agents from any and all liability of any type as a result of providing information to the above-mentioned person and/or company.

Previous Employer Name
{employer-name-PE4:402}

Contact Person

________________________________________

Mailing Address
{home-address (Street Address):313.1} {home-address (Address Line 2):313.2}
{home-address (City):313.3}, {home-address (State / Province):313.4}{home-address (ZIP / Postal Code):313.5}

Phone Number
{phone-number:14}

Fax Number

________________________________________

Dates of Employ
{dates-PE4:425}

Signature - 4th Past Employer

REQUEST FOR DRIVER'S SAFETY PERFORMANCE HISTORY INFORMATION FROM DOT REGULATED EMPLOYER(S)

5th Past Employer Carrier
{employer-name-PE5:401}

As a Commercial Motor Vehicle (CMV) Driver, I, {Name (First):13.3} {Name (Last):13.6},understand that per the Federal Motor Carrier Safety Regulations (FMCSRs) Part 391.21, the following information wIll be requested from all previous Employers for which I operated a CMV, subject to the FMCSR Parts 390 and/or 40, 382 & 383, within the past three years, from date shown below. I also acknowledge that this information will be used in determining my eligibility to be hired, that I have the right to review this information and rebut any errors in these statements from my prior employers, as described in the FMCSR Part 391.23.

I, {Name (First):13.3} {Name (Last):13.6}, hereby authorize this Company to release all records of employment, including assessments of job performance, ability and fitness including dates of any and all alcohol or drug tests, those confirmed results and/or my refusal to submit to any alcohol or drug test and any rehabilitation completion under direction of (SAP/MOR) to each and every company (or their authorized agents) which may request such information in connection with my application for employment with Company. I hereby release the company and its employees, officers, directors and agents from any and all liability of any type as a result of providing information to the above-mentioned person and/or company.

Previous Employer Name
{employer-name-PE5:401}

Contact Person

________________________________________

Mailing Address
{home-address (Street Address):313.1} {home-address (Address Line 2):313.2}
{home-address (City):313.3}, {home-address (State / Province):313.4}{home-address (ZIP / Postal Code):313.5}

Phone Number
{phone-number:14}

Fax Number

________________________________________

Dates of Employ
{dates-PE5:424}

Signature - 5th Past Employer

Email
This field is for validation purposes and should be left unchanged.

Application for Qualification

Application Error

Driver Personal Information

Contact Information

Previous Home Addresses

Emergency Contact

References

Education History

Job Performance

Prior Employment

Employment History

Present Or 1st Past Employer

2nd Past Employer

3rd Past Employer

4th Past Employer

5th Past Employer

Driving Experience

Accident Record

Driver's Licenses

Legal Actions

Traffic Violation and Review Record

Driver Applicant Drug and Alcohol Pre-Employment Statement

Controlled Substance & Alcohol Testing Information Acknowledgement & Consent Form

APPLICANT AUTHORIZATION CONSENT FOR RELEASE OF INFORMATION

DRIVER'S RIGHTS PERTAINING TO RELEASE OF DRIVER INFORMATION UNDER REGULATION 391.23

REQUEST FOR DRIVER'S SAFETY PERFORMANCE HISTORY INFORMATION FROM DOT REGULATED EMPLOYER(S)

SECTION I: DRUG & ALCOHOL INFORMATION

SECTION II: ACCIDENT INFORMATION

SECTION III: WORK HISTORY INFORMATION

REQUEST FOR DRIVER'S SAFETY PERFORMANCE HISTORY INFORMATION FROM DOT REGULATED EMPLOYER(S)

REQUEST FOR DRIVER'S SAFETY PERFORMANCE HISTORY INFORMATION FROM DOT REGULATED EMPLOYER(S)

REQUEST FOR DRIVER'S SAFETY PERFORMANCE HISTORY INFORMATION FROM DOT REGULATED EMPLOYER(S)

REQUEST FOR DRIVER'S SAFETY PERFORMANCE HISTORY INFORMATION FROM DOT REGULATED EMPLOYER(S)

REQUEST FOR DRIVER'S SAFETY PERFORMANCE HISTORY INFORMATION FROM DOT REGULATED EMPLOYER(S)