#1 Previous Address
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EMPLOYMENT AND SAFETY PERFORMANCE HISTORY
All driver applicants to drive in interstate commerce must provide the following information on all employers during the preceding 3 years. List complete mailing address, street number, city, state, and zip code. Applicants to drive a commercial motor vehicle* in intrastate or interstate commerce shall also provide an additional 7 years' information on those employers for whom the applicant operated such vehicle.(NOTE: List employers starting with the most recent. Add another sheet as necessary.)
* Includes vehicles having a GVWR of 26,001 lbs. or more, vehicles designed to transport 16 or more passengers (including the driver), or any size vehicle used to transport hazardous materials in a quantity requiring placarding.
**The Federal Motor Carrier Safety Regulations (FMCSRs) apply to anyone operating a motor vehicle on a highway in interstate commerce to transport passengers or property when the vehicle: (1) weighs or has a GVWR of 10,001 pounds or more, (2) is designed or used to transport 8 or more passengers (including the driver), OR (3) is of any size and is used to transport hazardous materials in a quantity requiring placarding.
I agree that my typed initials below will be as valid as a handwritten signature to the extent allowed by local law
ACCIDENT RECORD FOR PAST 3 YEARS OR MORE (ATTACH SHEET IF MORE SPACE IS NEEDED) IF NONE, WRITE NONE
complete to the best of my knowledge.
COPY OF CDL
COPY OF SNN CARD
COPY OF FMCSA MEDICAL CARD
COPY OF FMCSA MEDICAL VARIANCE
PREVIOUS PRE-EMPLOYMENT EMPLOYEE ALCOHOL AND DRUG TEST STATEMENT
Sec. 40.25(j) As the employer, you must also ask the employee 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 work covered by DOT agency drug and alcohol testing rules during the past two years. If the employee admits that he or she had a positive test or a refusal to test, you must not use the employee to perform safety-sensitive functions for you, until and unless the employee documents successful completion of the return-to-duty process. (see Sec. 40.25(b)(5) and (e))
PRE-EMPLOYMENT URINALYSIS NOTIFICATION
The Federal Motor Carrier Safety Regulations, Section 382.113– pre-employment testing requirements, apply to driver-applicants of this company.
DRUG & ALCOHOL AWARENESS PROGRAM CERTIFIED RECEIPT
EMERGENCY CONTACT INFORMATION
REQUEST FOR CHECK OF DRIVING AND CRIMINAL RECORDS
EMPLOYEE DRUG & ALCOHOL CONSENT FORM
COMPANY POST ACCIDENT DRUG & ALCOHOL TEST REQUIREMENTS
Any driver who is involved in a D.O.T. recordable accident is issued a citation for a moving violation as a result of that accident must submit to drug testing no later than (2) hours after the accident and must submit to alcohol testing no later than (2) hours after the accident.
DRIVER DATA SHEET
Instructions: Motor carriers when using a driver for the first time or immediately 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.
I hereby certify that the information given is correct to the best of my knowledge and belief, and I was last relieved from work at:
U.S. CITIZENSHIP AND IMMIGRATION SERVICES
I am aware that federal law provides for imprisonment and/or fines for false statements or use of false documents in connection with the completion of this form.
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