Application For Employment
IN COMPLIANCE WITH FEDERAL AND STATE EQUAL EMPLOYMENT OPPORTUNITY LAWS, QUALIFIED APPLICANTS ARE CONSIDERED FOR ALL POSITIONS WITHOUT REGARD TO RACE, COLOR, RELIGION, SEX, NATIONAL ORIGIN, AGE, MARITAL STATUS, OR NON-JOB RELATED DISABILITY.
Address for the past three years:
List employers in reverse order, beginning with the most recent.
LIST EVERY JOB YOU HAVE HAD IN THE PAST TEN YEARS BE SURE TO INCLUDE A VALID ADDRESS AND PHONE NUMBER. IF UNEMPLOYED OR SELF-EMPLOYED, PLEASE LIST WITH DATES.THERE CANNOT BE ANY TIME GAPS IN THIS 10 YEARS HISTORY
NOTICE TO CARRIERS: The requirements in Part 383 of the Federal Motor Carrier Safety Regulations 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 materials that require placarding.
The requirements in Part 391 apply to every driver who operates in interstate commerce and operates a vehicle
weighing 10,001 pounds or more, can transport more than 15 people, or transpons hazardous materials that require
DRIVER REQUIREMENTS: Parts 383 and 391 of the Federal Motor Carrier Safety Regulations contain
some requirements which you, as a driver, must comply. These requirements are in effect as of July 1, 1987.
They are as follows:
Request for Check of Driving Record
I hereby authorize you to release the following information to (Prospective Employer) for the purpose of investigation as required by section 391.23 of the Federal Motor Carrier Safety Regulations. You are hereby released from any and all liability which may result from furnishing such information.
THE FOLLOWING NAMED PERSON HAS MADE APPLICATION WITH OUR COMPANY FOR THE POSITION OF DRIVER. AS IN ACCORDANCE WITH SECTION 391.23, FEDERAL DEPARTMENT OF TRANSPORTATION REGULATIONS, PLEASE FURNISH THE UNDERSIGNED WITH THE APPLICANT'S DRIVING RECORD FOR THE PAST THREE YEARS.
The person named above has applied to this company for employment. This applicant lists your firm as past employer. Please complete the following items:
If the above applicant was employed as a driver with your company. Department of Transportation regulation section 382.405 (f) and (h) require that you provide the following information:
Prospective employer did not provide signed release from driver ($40.321(b)). Therefore, drug/alchol information cannot be provided.
Under DOT drug and alcohol testing requirements for the past 3 years:
In providing this information, any drug or alcohol testing information obtained from previous employers under $40.25 or other applicable DOT regulations is included.
FMCSA Regulation $395.86(2) states that mo1or carriers, when using a driver for the first time or intermittently, shall obtain trom the driver a signed statement giving the total time on duty during the immediately preceding 7 days and the time at which the driver was last relieved from duty prior to beginning work for the motor carriers.
Instructions: In the grid below, write the date and hours you worked, driving or not, for the past seven days. Write your total hours in the "TOTAL" column.
If there are any questions regarding the above stated drug and alcohoł palicy, you may contact your
company representative, CHRIS RIYERS @ 251-219-7558 or Motor Carrier Consultants at 251-433-4111.
I, understand and agree to abide by the above requirements and statement as a condition of employment.
Prior to releasing driver for said examination, The Company requests them to sign a consent form. This
consent form will apply to any D.0.T. required drug/alcohol screen performed while driver is employed by The Company.
Voluntary Submission for Physical Examination, Breath/Saliva Analysis, (when performed under the guidelines specified in CFR 49,3382.303] and/or Urine Analysis and the Release of Said Results.
I hereby authorize the release of the results of the examination ta The Company and its representatives. By this authorization, I do hereby release any doctor, hospital, medical center, clinic, medical personnel, etc. and The Company or any of its representatives from any and all liabilities arising from the release or use of the information contained in my physical exam and test results.
COMPANY INSTRUCTONS: Each motor carrier shall at least once every 12 months, require each driver it employs to preparE and furnish it with a list or all violations of motor vehicle fraffic 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 raquired by the motor cartier 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 (seclion 391.27).
If no violations are listed above. I certify that I have not been convicted nor forfeited bond or collateral on account of any viołation (other than those have provided under Part 383) required to be listed durlng the past 12 months.
SHOULD YOU DECIDE TO LEAVE EMPLOYMENT WITHIN SIX MONTHS TO ONE
YEAR (1 YEAR) OR ARE DISCHARGED FOR CAUSE DURING THIS PERIOD, YOU
AGREE TO REIMBURSE THE COMPANY FOR ALL EXPENSES INCURRED IN
ESTABLISHING AND MAINTAINING YOUR ELIGIBILITY, INCLUDING, BUT NOT
LIMITED TO, ALL COSTS RELATING TO DRUG TESTING, BACKGROUND CHECKS
AND MEDICAL EXAMINATIONS. SUCH EXPENSES MAY BE DEDUCTED FROM ANY
SUMS DUE TO YOU AT THE TIME OF YOUR LEAVING EMPLOYMENT.
THESE EXPENSES ARE LISTED, BUT NOT LIMITED TO, THE FOLLOWING:
PRE-EMPLOYMENT DRUG TESTING $75.00
D.0.T. PHYSICAL $50.00
DRIVERS FILES (COMPLETED) $20.00
SPECIAL PERMITS $75.00
UNIFIED CARRIER REGISTRATION $80.00
UNIFIED CARRIER REGISTRATION $20.00
UNIFIED CARRIER REGISTRATION $50.00
(As required by Title 49, Subtitle B, Chapter III, Subchapter B, Part 391, Subpart §382.703)
I understand that if the limited query conducted by the Company indicates that drug or alcohol violatlon information about me exists in the Clearinghouse, the FMCSA will not disclose that information to the Company without first obtaining additional specific consent from me. I aiso understand that in order to provide specific consent, I must register with the Clearinghouse and provide consent within the Clearinghouse.
I further understand that if I refuse to provide consent for the Company to conduct a query of the Clearinghouse, the Company must prohibit me from performing safety-sensitive functions, including driving a commercial motor vehicle, as required by FMCSA's drug and alcohol program regulations.
BEFORE MCCI CAN PROCESS ANY NEW DRIVER APPLICATIONS, THE DRIVER MUST COMPLETE THEIR CLEARINGHOUSE REGISTRATiON. FMcSA REQUIRES ALL PROSPECTIVE EMPLOYERS TO RUN A FULL QUERY INTO EACH DRIVER'S DRUG AND ALCOHOL HISTORY THROUGH THE CLEARINGHOUSE. IN ORDER FOR MCCI TO COMPLETE THIS PROCESS, THE DRIVER MUST COMPLETE THE STEPS BELOW BEFORE YOU FORWARD THEIR DRIVER FILE TO MCO FOR PR0CESSING:
Your registration should be complete