Driver Supplement - Team Member Application for Employment
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Driver Supplement - Team Member Application for Employment ADDRESS FOR PAST THREE YEARS ________________________________________________________________________ (How Long) __________________ ________________________________________________________________________ (How Long) __________________ ________________________________________________________________________ (How Long) __________________
COMPLETE
Date of Birth (Not Discriminated Against Due to Age): ____________________________ How many days have you been absent from work in the past year? __________________________________________ On what date would you be available for work? __________________________________________________________ Are you on a layoff and subject to recall?
Yes
No Would you be willing to work out of town?
Were you subject to Federal Motor Carrier Safety Regulations while with a previous employer?
Yes Yes
No
No
If so please list employer here: ___________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ If so were the positions designated as a safety sensitive function in any DOT regulated mode subject to alcohol and controlled substance testing requirements? Yes No
EXPERIENCE IN THE OPERATION OF MOTOR VEHICLES Class of Equipment
Type of Equipment (Van, Tank, Plat, Etc.)
Approximate Numbers of Miles/Hours
Dates From/To
COMPLETE
Straight Truck Truck Tractor Semi- Trailer Material Handling Equipment
Buses Fuel Trailers Pole Trailers Twin Trailers Other
DRIVER’S LICENSES FOR THE PAST THREE YEARS
COMPLETE
(All driver’s licenses, including commercial, for past three years must be shown)
License No.
State
Class
Endorsements
Restrictions
Experation Date
EMPLOYMENT EXPERIENCE Give a complete record of all employment for the past 10 years. Use a separate section for any employment or self-employment history, if necessary. Your application will not be processed if it is not properly completed.
Employer Name
Dates Employed From
Work Performed To
Phone Address Job Title
Hourly Rate/Salary _______ Starting/Final ______ /______
Supervisor Reason for leaving Were you subject to Federal Motor Carrier Safety Regulations while with this Employer?
Yes
No
Was this job designated as a safety sensitive function in any DOT regulated mode subject to alcohol and controlled substance testing requirements? Yes No
Employer Name
Dates Employed From
Work Performed To
Phone Address Job Title
Hourly Rate/Salary _______ Starting/Final ______ /______
Supervisor
COMPLETE
Reason for leaving Were you subject to Federal Motor Carrier Safety Regulations while with this Employer?
Yes
No
Was this job designated as a safety sensitive function in any DOT regulated mode subject to alcohol and controlled substance testing requirements? Yes No
Employer Name
Dates Employed From
Work Performed To
Phone Address Job Title
Hourly Rate/Salary _______ Starting/Final ______ /______
Supervisor Reason for leaving Were you subject to Federal Motor Carrier Safety Regulations while with this Employer?
Yes
No
Was this job designated as a safety sensitive function in any DOT regulated mode subject to alcohol and controlled substance testing requirements? Yes No
Employer Name
Dates Employed From
Work Performed To
Phone Address Job Title
Hourly Rate/Salary _______ Starting/Final ______ /______
Supervisor Reason for leaving Were you subject to Federal Motor Carrier Safety Regulations while with this Employer?
Yes
No
Was this job designated as a safety sensitive function in any DOT regulated mode subject to alcohol and controlled substance testing requirements? Yes No
Have you EVER been denied a license, permit, or privilege to operate a motor vehicle?
Yes
No
If yes, where? _________________________________________________________ When? _________________________ Is you license to drive suspended or revoked at this time, in any state?
Yes
No
COMPLETE
If yes, where? _________________________________________________________ When? _________________________ Has any license, permit, or privilege to drive EVER been suspended ot revoked?
Yes
No
If yes, Where? ______________________________ When? _____________ Why? __________________________________ Is your driving privilege limited in any way, such as probation, area of operation, limitation of hours, etc., at this time?
Yes
No
If yes, where? _________________________________________________________ When? _________________________ Are you familiar with D.O.T. Motor Carrier Safety Regulations? Do you agree to follow them?
Yes
Yes
No
No
MOTOR VEHICLE ACCIDENT RECORD (List accidents for the past three years)
Where
Nature of Accident (HeadOn, Rear-End, Etc.)
Number of Injuries
Fatalities
Type of Vehicle You Were Driving
COMPLETE
Date
MOTOR VEHICLE LAW OR ORDINANCE MOVING VIOLATIONS FROM PAST THREE YEARS (It is not required to include violations involving only parking)
COMPLETE
Date
Where
Charge)
Penalty
Conviction?
Forfeit Bond or Collateral?
OTHER WIll you take an alcohol/drug screen breath/urine test for drug and alcohol or controlled substances? Yes
No
Have you EVER been convicted for use of alcohol?
Yes
No
COMPLETE
If yes, where? __________________________________________________________ When? ________________________ Was a vehicle involved?
Yes
No
If yes, what type?
Personal
Commercial
If yes, what charge? ___________________________________________________________________________________ Have you EVER been convicted for use or possession of drugs ot controlled substances?
Yes
No
If yes, where? __________________________________________________________ When? ________________________ Was a vehicle involved?
Yes
No
If yes, what type?
Personal
Commercial
If yes, what charge? ___________________________________________________________________________________ Conviction will not necessarily disqualify you from employment. The recency, severity, and pertinence of the conviction to the job will all be considered.
ACKNOWLEDGMENTS This certifies that the driver supplement to the Viafield team member employment application was completed by me and that all entires on it and information in it are true to and complete to the best of my knowledge. Viafield may investigate all statements contained in this supplement, or information provided post-offer including medical examinations, and I understand that any false ot misleading information provided may result in my immediate discharge if I am hired. I under stand that the information in this section of the Viafield team member employment application will be used and that prior reployers will me contacted for purposes of investigation, as required by Sec. 391.23 of Department of Transportation Regulations. I understand I have the right to: Review information provided by previous employers Have errors in the information corrected by previous employers and for those previous employers to re-send the corrected information to the prospective employer: and Have a rebuttal statement attached to the alleged erroneous information, if the previous employer(s) and I cannot agree on the accuracy of the information.
Signature of Applicant Date
FOR OFFICE USE ONLY Hire Date: _____________ Position: ___________________ Company Representative: _______________________ Termination Date: _________________ Company Representative: ________________________________________
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PRE-EMPLOYMENT DRUG TESTING NOTIFICATION AND CONCENT Before collection of a urine sample from a driver/applicant, you must have this form completed and on file. Type or photocopy this form onto your Viafield letterhead. I understand that, as required by the Federal Motor Carrier Safety Regulations 49 CFR Part 382 and company policy, all prospective drivers must submit to a controlled substances test involving collection of a urine sample that will be tested for the following controlled substances: marijuana, cocaine, opiates, amphetamines and phencyclidine (PCP). I understand that, if I test positive for use of controlled substances, I am not medically qualified to operate a commercial motor vehicle. I also understand I will be given a reasonable opportunity to confer with Viafield whether the test result was negative ot positive. The results of any tests will not be released to any additional parties, except as provided in 40.37, without my written authorization. I hereby agree to submit to a urnie drug test. Date: Team Member Name (PRINT): Team Member Signature:
AUTHORIZATION AND RELEASE TO OBTAIN INFORMATION Under the previsions of the Fair Credit Reporting Act, 15 USC, Section 1681 et seq., The Americans with Disabilities Act and all applicable federal, state, and local laws, I hereby authorize and permit Viafield to obtain a consumer report and/or an investigating consumer report once per year whil employed at Viafield, which may include the following: 1. Records concerning any driving , workers’ compensation (post-offer only) and drug testing. 2. (For truck drivers only) In accordance with the Department of Transportation Motor Carrier Safety Regulations, Section 382.413, information concerning alcohol and controlled substances for the past 2 years. I agree that a copy of this authorization has the same effect as an origianl. I hereby release and hold harmless any person, firm, or entity that discloses matters in accordance with this authorization, as well as from liability that might otherwise result from the request for use of and/or disclosure of any or all of the foregoing information. I understand and acknowledge that under provision of the Fair Credit Reporting Act I may request a copy of any consumer report from the consumer-reporting agency that compiled the report, after I have provided proper identification. I hereby authorize Viafield to obtain and prepare an ivestigative consumer report as set forth above, as part of its investigation of my continued employement. Date: Team Member Name (PRINT): Team Member Signature:
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PREVIOUS PRE-EMPLOYMENT ALCOHOL/CONTROLLED SUBSTANCE TEST STATEMENT In accordance with Sec. 40.25(j), Sec. 40.25(b) =(5) and (e) we are required to ask the following:
COMPLETE
Applicant Name: ______________________________________________________________________________________ Applicant Social Security #: _____________________________________________________________________________ Have you tested positive, or refused to test, on any pre-employment drug or alcohol test administered by an employer to which you appled for, but did not obtain, safety-sensitive transportation work covered by DOT agency drug and alcohol testing rules during the past two years? Check one:
Yes
No
If you answered yes, can you provide/obtain proof that you’ve successfully completed the DOT return-to-duty requirements? Check one:
Yes
No
I certify that the information proved on the document is true and correct. Applicant Signature: Date: Witnessed by: ___________________________________________________________ Date: ______________________
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DRIVERS RELEASE OF MVR Drivers Name (Print): ______________________________________
COMPLETE
License State: ____________________________________________ Driver License Number: ____________________________________ Date of Birth: ____________________________________________ Social Security #: _________________________________________
I, __________________________________, Do hereby authorize all applicable State Department of Mot Vehicles to (First & Last Name)
release any and all information pertaining to my driving recore to Viafield or its designee. This authorization shall remain in effect for the duration of my employment with the company.
Signed: Date:
(this form must be maintained for three years after employment is terminated)
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CERTIFICATION OF VIOLATIONS Applicants Name: _____________________________________________________________________________________ Driver’s License #: _____________________________________________________________________________________
PART 1 I certify that the following is a true and complete list of all traffic violations (other than parking violations), for which I have been convicted or forefeited bond or collateral during the preceding 12 month period.
Offense
Location
Type of Vehicle Operated
COMPLETE
Date
If no violations are listed above, I certify that I have not been convicted or forefieted bond or collateral for any violations required to be listed during the preceding 12 month period. Date of Certification: Drivers Signature: Company Name: Viafield (A Cooperative)
Location:
Reviewed By: Title:
PART 2 In accordance with 49 CFR part 391.25 of the Federal Motor Carrier Safety Regulation, I have reviewed all information pertinent to: _____________________ Driving record including the list of violations furnished in accordance with 49 CFR part 391.27. Check One: Qualified:
Not Qualified:
Company Name: Viafield (A Cooperative)
Location: _________________________________________
Reviewed by: ______________________________ Title: _____________________________________________
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Date sent to previous employer: ________________________
DOT DRIVER SAFETY HISTORY RECORDS REQUEST SECTION 1: TO BE COMPLETED BY PROSPECTIVE TEAM MEMBER
COMPLETE
I, _________________________________________ ____________________________________ _______________ (print) First, M.I., Last) Social Security Number Date of Birth Hereby Authorize; Previous Employer: ____________________________________________________________________________________ Street: ________________________________________________ Telephone : ____________________________________ City, State, Zip: _________________________________________ Fax No.: _______________________________________ To release and forward the information requested by section 3 of this document concerning my Alcohol and Controlled Substances Testing records within the previous 3 years from _________________________________ . (date of employment application) To: Prospective Employer: ______________________________________________ Attention: ________________________________________________ Telephone: ___________________________ Street: ___________________________________________________________ City, State, Zip: ____________________________________________________
In compliance with 40.25(g) and 391.23(h). release of this information must be made in writing for that ensures confidentiality, such as fax, email, or letter within 30 days of receipt. Prospective employer’s confidential fax number: ______________________________________________________ Prospective employer’s confidential email address: ____________________________________________________ Applicant’s Signature: Date: This information is being requested in compliance with 40.25 and 391.23
SECTION 2: TO BE COMPLETED BY PREVIOUS EMPLOYER The applicant named above was employed by us.
Yes
No
Employed as: _____________________________ From (m/yr) ___________________ To (m/yr) ______________________ Did he/she drive a motor vehicle for you?
Yes
No
If yes, what type of truck?
Straight Truck
Tractor-Semi-trailer
Bus
Cargo Tank
If there is no safety performance history to report, check here:
Doubles/Triples
Other _________
sign below and continue to section 3.
ACCIDENTS: Complete the following for any accidents included on your accident register (39Q.15(b)) that involved the applicant in the 3 years prior to the application date shown above, or leave blank if there is no accident register data for this driver.
Date:
Location:
No. of injuries
No. of Fatalities or Hazmat Spill
1. ____________________________________________________________________________________________ 2. ____________________________________________________________________________________________ 3. ____________________________________________________________________________________________ Please provide information concerning any other accidents involving the applicant that were reported to government agencies or insurers or retained under internal company policies. ____________________________________________________________________________________________________ ____________________________________________________________________________________________________
SECTION 3: TO BE COMPLETED BY PREVIOUS EMPLOYER Controlled Substance and Alcohol Testing History If driver was not subject to DOT testing requirements while employed by this employer, please check here dates of employment from ___________ to __________ complete the bottom of section 3, sign and return.
and fill in
Driver was subject to DOT testing requirements from ______________ to _____________
Yes
No
Has this person had an alcohol test with a result of 0.04 or higher alcohol concentration?
Yes
No
Has this person tested positive ot adulterated or substituted a test specimen for controlled substances?
Yes
No
Has this person refused to submit to a post-accident, random, reasonable suspicion, or follow-up alcohol or controlled substance test?
Yes
No
Has this person committed other violations of Subpart B of Part 382 ot Part 40?
Yes
No
If this person has violated a DOT drug and alcohol regulation, did this person fail to undertake or complete a program prescribed by a Substance Abuse Professional (SAP) in you employ? If yes, please send documentation back with this form.
Yes
No
For a driver who successfully completed a SAP’s rehabilitation referral and remained in your employment, did this driver subsequantly have an alcohol test result having an alcohol test result of 0.04 or greater, a verified positive drug test, or refuse to be tested?
Yes
No
In answering these questions, include any required DOT Controlled substance or alcohol testing information obtained from prior previous employers in the previous 3 years prior to application date show on section 1?
Yes
No
Name: _______________________________________________________________________________________________ Company: ___________________________________________________________________________________________ Street: ______________________________________________________________________________________________ City, State, ZIP: _________________________________________________ Telephone: ____________________________ Completed by (signature): ______________________________________________________ Date: __________________
SECTION 4a: TO BE COMPLETED BY PROSPECTIVE EMPLOYER This form was (check one):
Faxed to previous employer
Mailed
Emailed
Other
By (Signature) ____________________________________________________________ Date: ____________________
SECTION 4b: TO BE COMPLETED BY PROSPECTIVE EMPLOYER Complete below when returned information is obtained from previous employer Information received from: __________________________________ Method: Fax
Mail
Email
Other
Recorded by: ____________________________________________________________ Date: _____________________
Driver Supplement - Team Member Application for Employment ADDRESS FOR PAST THREE YEARS ________________________________________________________________________ (How Long) __________________ ________________________________________________________________________ (How Long) __________________ ________________________________________________________________________ (How Long) __________________
COMPLETE
Date of Birth (Not Discriminated Against Due to Age): ____________________________ How many days have you been absent from work in the past year? __________________________________________ On what date would you be available for work? __________________________________________________________ Are you on a layoff and subject to recall?
Yes
No Would you be willing to work out of town?
Were you subject to Federal Motor Carrier Safety Regulations while with a previous employer?
Yes Yes
No
No
If so please list employer here: ___________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ If so were the positions designated as a safety sensitive function in any DOT regulated mode subject to alcohol and controlled substance testing requirements? Yes No
EXPERIENCE IN THE OPERATION OF MOTOR VEHICLES Class of Equipment
Type of Equipment (Van, Tank, Plat, Etc.)
Approximate Numbers of Miles/Hours
Dates From/To
COMPLETE
Straight Truck Truck Tractor Semi- Trailer Material Handling Equipment
Buses Fuel Trailers Pole Trailers Twin Trailers Other
DRIVER’S LICENSES FOR THE PAST THREE YEARS
COMPLETE
(All driver’s licenses, including commercial, for past three years must be shown)
License No.
State
Class
Endorsements
Restrictions
Experation Date
EMPLOYMENT EXPERIENCE Give a complete record of all employment for the past 10 years. Use a separate section for any employment or self-employment history, if necessary. Your application will not be processed if it is not properly completed.
Employer Name
Dates Employed From
Work Performed To
Phone Address Job Title
Hourly Rate/Salary _______ Starting/Final ______ /______
Supervisor Reason for leaving Were you subject to Federal Motor Carrier Safety Regulations while with this Employer?
Yes
No
Was this job designated as a safety sensitive function in any DOT regulated mode subject to alcohol and controlled substance testing requirements? Yes No
Employer Name
Dates Employed From
Work Performed To
Phone Address Job Title
Hourly Rate/Salary _______ Starting/Final ______ /______
Supervisor
COMPLETE
Reason for leaving Were you subject to Federal Motor Carrier Safety Regulations while with this Employer?
Yes
No
Was this job designated as a safety sensitive function in any DOT regulated mode subject to alcohol and controlled substance testing requirements? Yes No
Employer Name
Dates Employed From
Work Performed To
Phone Address Job Title
Hourly Rate/Salary _______ Starting/Final ______ /______
Supervisor Reason for leaving Were you subject to Federal Motor Carrier Safety Regulations while with this Employer?
Yes
No
Was this job designated as a safety sensitive function in any DOT regulated mode subject to alcohol and controlled substance testing requirements? Yes No
Employer Name
Dates Employed From
Work Performed To
Phone Address Job Title
Hourly Rate/Salary _______ Starting/Final ______ /______
Supervisor Reason for leaving Were you subject to Federal Motor Carrier Safety Regulations while with this Employer?
Yes
No
Was this job designated as a safety sensitive function in any DOT regulated mode subject to alcohol and controlled substance testing requirements? Yes No
Have you EVER been denied a license, permit, or privilege to operate a motor vehicle?
Yes
No
If yes, where? _________________________________________________________ When? _________________________ Is you license to drive suspended or revoked at this time, in any state?
Yes
No
COMPLETE
If yes, where? _________________________________________________________ When? _________________________ Has any license, permit, or privilege to drive EVER been suspended ot revoked?
Yes
No
If yes, Where? ______________________________ When? _____________ Why? __________________________________ Is your driving privilege limited in any way, such as probation, area of operation, limitation of hours, etc., at this time?
Yes
No
If yes, where? _________________________________________________________ When? _________________________ Are you familiar with D.O.T. Motor Carrier Safety Regulations? Do you agree to follow them?
Yes
Yes
No
No
MOTOR VEHICLE ACCIDENT RECORD (List accidents for the past three years)
Where
Nature of Accident (HeadOn, Rear-End, Etc.)
Number of Injuries
Fatalities
Type of Vehicle You Were Driving
COMPLETE
Date
MOTOR VEHICLE LAW OR ORDINANCE MOVING VIOLATIONS FROM PAST THREE YEARS (It is not required to include violations involving only parking)
COMPLETE
Date
Where
Charge)
Penalty
Conviction?
Forfeit Bond or Collateral?
OTHER WIll you take an alcohol/drug screen breath/urine test for drug and alcohol or controlled substances? Yes
No
Have you EVER been convicted for use of alcohol?
Yes
No
COMPLETE
If yes, where? __________________________________________________________ When? ________________________ Was a vehicle involved?
Yes
No
If yes, what type?
Personal
Commercial
If yes, what charge? ___________________________________________________________________________________ Have you EVER been convicted for use or possession of drugs ot controlled substances?
Yes
No
If yes, where? __________________________________________________________ When? ________________________ Was a vehicle involved?
Yes
No
If yes, what type?
Personal
Commercial
If yes, what charge? ___________________________________________________________________________________ Conviction will not necessarily disqualify you from employment. The recency, severity, and pertinence of the conviction to the job will all be considered.
ACKNOWLEDGMENTS This certifies that the driver supplement to the Viafield team member employment application was completed by me and that all entires on it and information in it are true to and complete to the best of my knowledge. Viafield may investigate all statements contained in this supplement, or information provided post-offer including medical examinations, and I understand that any false ot misleading information provided may result in my immediate discharge if I am hired. I under stand that the information in this section of the Viafield team member employment application will be used and that prior reployers will me contacted for purposes of investigation, as required by Sec. 391.23 of Department of Transportation Regulations. I understand I have the right to: Review information provided by previous employers Have errors in the information corrected by previous employers and for those previous employers to re-send the corrected information to the prospective employer: and Have a rebuttal statement attached to the alleged erroneous information, if the previous employer(s) and I cannot agree on the accuracy of the information.
Signature of Applicant Date
FOR OFFICE USE ONLY Hire Date: _____________ Position: ___________________ Company Representative: _______________________ Termination Date: _________________ Company Representative: ________________________________________
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PRE-EMPLOYMENT DRUG TESTING NOTIFICATION AND CONCENT Before collection of a urine sample from a driver/applicant, you must have this form completed and on file. Type or photocopy this form onto your Viafield letterhead. I understand that, as required by the Federal Motor Carrier Safety Regulations 49 CFR Part 382 and company policy, all prospective drivers must submit to a controlled substances test involving collection of a urine sample that will be tested for the following controlled substances: marijuana, cocaine, opiates, amphetamines and phencyclidine (PCP). I understand that, if I test positive for use of controlled substances, I am not medically qualified to operate a commercial motor vehicle. I also understand I will be given a reasonable opportunity to confer with Viafield whether the test result was negative ot positive. The results of any tests will not be released to any additional parties, except as provided in 40.37, without my written authorization. I hereby agree to submit to a urnie drug test. Date: Team Member Name (PRINT): Team Member Signature:
AUTHORIZATION AND RELEASE TO OBTAIN INFORMATION Under the previsions of the Fair Credit Reporting Act, 15 USC, Section 1681 et seq., The Americans with Disabilities Act and all applicable federal, state, and local laws, I hereby authorize and permit Viafield to obtain a consumer report and/or an investigating consumer report once per year whil employed at Viafield, which may include the following: 1. Records concerning any driving , workers’ compensation (post-offer only) and drug testing. 2. (For truck drivers only) In accordance with the Department of Transportation Motor Carrier Safety Regulations, Section 382.413, information concerning alcohol and controlled substances for the past 2 years. I agree that a copy of this authorization has the same effect as an origianl. I hereby release and hold harmless any person, firm, or entity that discloses matters in accordance with this authorization, as well as from liability that might otherwise result from the request for use of and/or disclosure of any or all of the foregoing information. I understand and acknowledge that under provision of the Fair Credit Reporting Act I may request a copy of any consumer report from the consumer-reporting agency that compiled the report, after I have provided proper identification. I hereby authorize Viafield to obtain and prepare an ivestigative consumer report as set forth above, as part of its investigation of my continued employement. Date: Team Member Name (PRINT): Team Member Signature:
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PREVIOUS PRE-EMPLOYMENT ALCOHOL/CONTROLLED SUBSTANCE TEST STATEMENT In accordance with Sec. 40.25(j), Sec. 40.25(b) =(5) and (e) we are required to ask the following:
COMPLETE
Applicant Name: ______________________________________________________________________________________ Applicant Social Security #: _____________________________________________________________________________ Have you tested positive, or refused to test, on any pre-employment drug or alcohol test administered by an employer to which you appled for, but did not obtain, safety-sensitive transportation work covered by DOT agency drug and alcohol testing rules during the past two years? Check one:
Yes
No
If you answered yes, can you provide/obtain proof that you’ve successfully completed the DOT return-to-duty requirements? Check one:
Yes
No
I certify that the information proved on the document is true and correct. Applicant Signature: Date: Witnessed by: ___________________________________________________________ Date: ______________________
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DRIVERS RELEASE OF MVR Drivers Name (Print): ______________________________________
COMPLETE
License State: ____________________________________________ Driver License Number: ____________________________________ Date of Birth: ____________________________________________ Social Security #: _________________________________________
I, __________________________________, Do hereby authorize all applicable State Department of Mot Vehicles to (First & Last Name)
release any and all information pertaining to my driving recore to Viafield or its designee. This authorization shall remain in effect for the duration of my employment with the company.
Signed: Date:
(this form must be maintained for three years after employment is terminated)
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CERTIFICATION OF VIOLATIONS Applicants Name: _____________________________________________________________________________________ Driver’s License #: _____________________________________________________________________________________
PART 1 I certify that the following is a true and complete list of all traffic violations (other than parking violations), for which I have been convicted or forefeited bond or collateral during the preceding 12 month period.
Offense
Location
Type of Vehicle Operated
COMPLETE
Date
If no violations are listed above, I certify that I have not been convicted or forefieted bond or collateral for any violations required to be listed during the preceding 12 month period. Date of Certification: Drivers Signature: Company Name: Viafield (A Cooperative)
Location:
Reviewed By: Title:
PART 2 In accordance with 49 CFR part 391.25 of the Federal Motor Carrier Safety Regulation, I have reviewed all information pertinent to: _____________________ Driving record including the list of violations furnished in accordance with 49 CFR part 391.27. Check One: Qualified:
Not Qualified:
Company Name: Viafield (A Cooperative)
Location: _________________________________________
Reviewed by: ______________________________ Title: _____________________________________________
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Date sent to previous employer: ________________________
DOT DRIVER SAFETY HISTORY RECORDS REQUEST SECTION 1: TO BE COMPLETED BY PROSPECTIVE TEAM MEMBER
COMPLETE
I, _________________________________________ ____________________________________ _______________ (print) First, M.I., Last) Social Security Number Date of Birth Hereby Authorize; Previous Employer: ____________________________________________________________________________________ Street: ________________________________________________ Telephone : ____________________________________ City, State, Zip: _________________________________________ Fax No.: _______________________________________ To release and forward the information requested by section 3 of this document concerning my Alcohol and Controlled Substances Testing records within the previous 3 years from _________________________________ . (date of employment application) To: Prospective Employer: ______________________________________________ Attention: ________________________________________________ Telephone: ___________________________ Street: ___________________________________________________________ City, State, Zip: ____________________________________________________
In compliance with 40.25(g) and 391.23(h). release of this information must be made in writing for that ensures confidentiality, such as fax, email, or letter within 30 days of receipt. Prospective employer’s confidential fax number: ______________________________________________________ Prospective employer’s confidential email address: ____________________________________________________ Applicant’s Signature: Date: This information is being requested in compliance with 40.25 and 391.23
SECTION 2: TO BE COMPLETED BY PREVIOUS EMPLOYER The applicant named above was employed by us.
Yes
No
Employed as: _____________________________ From (m/yr) ___________________ To (m/yr) ______________________ Did he/she drive a motor vehicle for you?
Yes
No
If yes, what type of truck?
Straight Truck
Tractor-Semi-trailer
Bus
Cargo Tank
If there is no safety performance history to report, check here:
Doubles/Triples
Other _________
sign below and continue to section 3.
ACCIDENTS: Complete the following for any accidents included on your accident register (39Q.15(b)) that involved the applicant in the 3 years prior to the application date shown above, or leave blank if there is no accident register data for this driver.
Date:
Location:
No. of injuries
No. of Fatalities or Hazmat Spill
1. ____________________________________________________________________________________________ 2. ____________________________________________________________________________________________ 3. ____________________________________________________________________________________________ Please provide information concerning any other accidents involving the applicant that were reported to government agencies or insurers or retained under internal company policies. ____________________________________________________________________________________________________ ____________________________________________________________________________________________________
SECTION 3: TO BE COMPLETED BY PREVIOUS EMPLOYER Controlled Substance and Alcohol Testing History If driver was not subject to DOT testing requirements while employed by this employer, please check here dates of employment from ___________ to __________ complete the bottom of section 3, sign and return.
and fill in
Driver was subject to DOT testing requirements from ______________ to _____________
Yes
No
Has this person had an alcohol test with a result of 0.04 or higher alcohol concentration?
Yes
No
Has this person tested positive ot adulterated or substituted a test specimen for controlled substances?
Yes
No
Has this person refused to submit to a post-accident, random, reasonable suspicion, or follow-up alcohol or controlled substance test?
Yes
No
Has this person committed other violations of Subpart B of Part 382 ot Part 40?
Yes
No
If this person has violated a DOT drug and alcohol regulation, did this person fail to undertake or complete a program prescribed by a Substance Abuse Professional (SAP) in you employ? If yes, please send documentation back with this form.
Yes
No
For a driver who successfully completed a SAP’s rehabilitation referral and remained in your employment, did this driver subsequantly have an alcohol test result having an alcohol test result of 0.04 or greater, a verified positive drug test, or refuse to be tested?
Yes
No
In answering these questions, include any required DOT Controlled substance or alcohol testing information obtained from prior previous employers in the previous 3 years prior to application date show on section 1?
Yes
No
Name: _______________________________________________________________________________________________ Company: ___________________________________________________________________________________________ Street: ______________________________________________________________________________________________ City, State, ZIP: _________________________________________________ Telephone: ____________________________ Completed by (signature): ______________________________________________________ Date: __________________
SECTION 4a: TO BE COMPLETED BY PROSPECTIVE EMPLOYER This form was (check one):
Faxed to previous employer
Mailed
Emailed
Other
By (Signature) ____________________________________________________________ Date: ____________________
SECTION 4b: TO BE COMPLETED BY PROSPECTIVE EMPLOYER Complete below when returned information is obtained from previous employer Information received from: __________________________________ Method: Fax
Other
Recorded by: ____________________________________________________________ Date: _____________________
