Driver Application Folder

Driver Application Folder

Key

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

~~~~~~~~~~~

app to your Manager

ALIMCO LOGISTICS LLC

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

~~~~~~~~~~~

Driver Name

____________________________ Driver ID No: __________

Date of Hire _______________ 1

day Driven: _______________________

Phone # ______________________

2

Phone # ________________

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

_________ Date of Medical Examination Report (Long Form)

_________ Date expires

_________ Date of Pre-Employment 5-panel drug screen

_________ Date of Results which were received by __Letter, __Fax__ Phone

_________ Copy Of CDL

_________

Copy of Social Security Card

_________

Copy of Green Card

_________ Application for Employment

____ Signed & dated

____ Complete record of past 10 years

unemployed, self-employed or out-of-country, note starting and ending dates)

____ record within last 3 years verified

____ Request for Information from Previous Employer

_________ Application Drug Consortium or Proof of Participation

_________ Certificate Of Drivers Road Test __________ CDL Used

_________ Drivers Road Examination __________ CDL Used

_________ Inquiry To State Agency, Drivers Record

_________ Prev. 7 Days Hours of Service [for 1

time

or

intermittent driver

_________ Signed Statements of receipt of Written Safety Plan

Manual with Drug & Alcohol Information Booklet & Employee Safety Manual from The Safety Department)

APPLICATION FOR EMPLOYMENT

TODAY’S DATE ______________ FIRST DAY TO DRIVE WITH THIS COMPANY__________________

NAME _______________________________________________SOC SEC. NO. __________________

(First) (Middle) (lLast)

CDL#________________STATE ____CLASS ____EXP DATE ____________DATE OF BIRTH _____________

ENDORSEMENTS: HAZMAT_______ TANK ______ DOUBLES______ TRIPLES ______OTHER _

ADDRESS___________________________________________________________________________ (Street) (City) (State) (Zip)

PREVIOUS ADDRESS: (Total of 3 years’ address MUST be provided, INCLUDING TIME AT PRESENT ADDRESS)

______________________________________________________________________________

(Street) (City) ( State) (Zip)

______________________________________________________________________________

(Street) (City) (State) (ZIP)

________________________________________________________________________________________________________ (Street) (City) ( State) (Zip)

(ATTACH SHEET IF MORE SPACE IS NEEDED)

DRIVER EXPERIENCE:

TYPE OF EQUIMENT FROM TO APROX # MILES TOTAL

STRAIGHT TRUCK TRACTOR&SEMI TRAILER TRACTOR TWO TRAILERS OTHER

ACCIDENT RECORD FOR PAST 3 YEARS OR MORE (ATTACH SHEET IF MORE SPACE IS NEEDED)

Dates

Nature of Accident Head-on, Rear-End, Upset, etc.

Number Fatalities Number Chemical Injuries Spills Yes No Yes No Yes No

TRAFFIC CONVICTIONS AND FORFEITURES FOR THE PAST 3 YEARS (OTHER THAN PARKING VIOLATIONS)

Date Nature of Violation State of Violation Location

Penalty

(forfeited bond, collateral/point)

A. Have you ever been denied a license, permit or privilege to operate a motor vehicle? Yes__ No __ If yes, explain ______________________________________________________________________

B. Has any license, permit or privilege ever been suspended or revoked ? Yes __ No _ If yes, explain ______________________________________________________________________

EMPLOYMENT RECORD: PLEASE give as much info as you can

If more paper is needed, please attach

IMPORTANT!!

Three years’ employment history MUST BE VERIFIABLE for ALL CDL applicants.

IF YOU HAVE ANY TIMES YOU WERE NOT EMPLOYED, PUT DATES AND REASON,

For example: UNEMPLOYED, OUT OF COUNTRY, FAMILY LEAVE, ETC.

All time you were not working must be explained.

PREVIOUS EMPLOYER or reason not working: (This is the job you just left or are still working for)

COMPANY__________________________________________________ ADDRESS __________________________________

CITY_________________ST_____ZIP____________ FAX _______________________ PHONE _________________________CONTACT PERSON ___________________ FAX: _____________________ (Driver, please call previous employer for fax #)

POSITION HELD ________________________ FROM __________ TO___________

SECOND LAST EMPLOYER or reason not working: COMPANY__________________________________________________ ADDRESS __________________________________ CITY_________________ST_____ZIP____________ FAX _______________________ PHONE _________________________CONTACT PERSON ___________________ FAX: _____________________ (Driver, please call previous employer for fax #)

POSITION HELD ________________________ FROM __________ TO___________

(If time employed is known, otherwise estimate as closely as possible) mo/day/year mo/day/year

THIRD LAST EMPLOYER: or reason not working:

COMPANY__________________________________________________ ADDRESS __________________________________

CITY_________________ST_____ZIP____________ FAX _______________________ PHONE _________________________CONTACT PERSON ___________________ FAX: _____________________ (Driver, please call previous employer for fax #)

POSITION HELD ________________________ FROM __________ TO___________

(If time employed is known, otherwise estimate as closely as possible) mo/day/year mo/day/year FORTH LAST EMPLOYER or reason not working:

COMPANY__________________________________________________ ADDRESS __________________________________

CITY_________________ST_____ZIP____________ FAX _______________________ PHONE _________________________CONTACT PERSON ___________________ FAX: _____________________ (Driver, please call previous employer for fax #)

(If time employed is known, otherwise estimate as closely as possible) mo/day/year mo/day/year FIFTH LAST EMPLOYER or reason not working:

COMPANY__________________________________________________ ADDRESS __________________________________

CITY_________________ST_____ZIP____________ FAX _______________________ PHONE _________________________CONTACT PERSON ___________________ FAX: _____________________ (Driver, please call previous employer for fax #)

POSITION HELD ________________________ FROM __________ TO___________

(If time employed is known, otherwise estimate as closely as possible) mo/day/year mo/day/year SIXTH LAST EMPLOYER or reason not working:

COMPANY__________________________________________________ ADDRESS __________________________________

CITY_________________ST_____ZIP____________ FAX _______________________ PHONE _________________________CONTACT PERSON ___________________ FAX: _____________________ (Driver, please call previous employer for fax #)

POSITION HELD ________________________ FROM __________ TO___________

(If time employed is known, otherwise estimate as closely as possible) mo/day/year mo/day/year

Please use more paper if more room is needed.

This certifies that the information above is true and complete to the best of my

knowledge.

_____________________

X

TO BE READ AND SIGNED BY APPLICANT:

In accordance with the provision 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 may be obtained on you for employment purposes. These reports are required by Sections 382.143, 391.23 and the Federal Motor Carrier Safety Regulations. (Within 5 days of a written request, you have the right to view any or all replies we obtain from previous employers.) Also, I understand, and give permission to take both pre-employment and Random Drug/Alcohol tests as required by FMCSA (382.601 (b)(2)).

_________________

X

Date Applicant’s Signature

Note: A Motor Carrier may require an applicant to provide additional information in accordance with the Federal Motor Carrier Safety Regulation

Employment and Controlled Substance Inquiry

(This document has been color-coded: Green is Inquiring Company; Blue is Previous Employer;

Red is Driver info

Your previous employee has applied to ALIMCO LOGISTICS LLC as a driver. Please fill out and return to:

Company: ALIMCO LOGISTICS, LLC Attn: _______________________________ Phone: _______________

Address _______________________________________St ____Zip ________ Fax: ________________ Attn: PREVIOUS EMPLOYER: Please assist us in our background check as per Part 391 of the FMCSR

Company Name ___________________________________ Attn: ______________________________

City/State ___________________________ Fax: _________________ Phone ________________

Driver: Complete Everything in Red

__________________________________________________________________

I authorize all my previous employers to release all information concerning my employment, including Drug and Alcohol Information to this company in connection with my application for employment. All parties involved shall not be held liable for the information that they furnish.

Applicant’s Name _______________________________________SSN:______________________

Please Print Name

Signature

X

Part A

1. The Applicant lists dates of Employment from _____________ to ____________ VERIFICATION FROM PREVIOUS EMPLOYER:

Are these dates correct?________ If not, please furnish correct dates from __________ to______ 2. What type of work did the applicant do? ________ Driver ______ Dock ______ Other ________ 3. Type of Driver _____ Company ______ O/O ______ Lease Purchase ______Trainee _____ Other 4. Areas of Operation ______ Local ______ Regional ______OTR ______ Other _____________ 5. Type of Equipment ______ Straight Truck ______ Tractor Trailer ______ Twin Trailer ______ 6. # of DOT record able Accidents ______ # of Preventable Accidents _______ Dates ___________ 7. Reason for Leaving _____ Resigned _______ Laid Off ______ Terminated ______ Other _____ 8. Eligible for rehire ______ Yes ______ No, If no, please explain ____________________

Part B

1. Was applicant subject to Federal Motor Carrier Safety Regulations ___yes____no 2. Was job designated as a safety sensitive function in any DOT regulated mode subject to alcohol and controlled substances testing requirements as required by 49CFR Part 40? YES NO Part C

Information supplied by previous employer per 49 CFR Part 382.405 (f) and

1. Has this person ever tested positive for a controlled substance in the last 3 years? YES NO 2. Has this person ever had an alcohol test BAC of .04 or greater in the last 3 years? YES NO 3. Has this person ever refused a required test for drugs or alcohol? (Including adulterated or substituted sample?) YES NO 4. Has this person had any violations of DOT agency drug or alcohol testing regulations? YES NO 5. Has this person violated any DOT drug and alcohol return-to-duty requirements?

(including follow-up testing) required successful SAP Completion? YES NO If YES to any of the above questions, please supply the name of the Substance Abuse

Professional to whom the driver was referred and any paperwork that applies to the instance being reported.

VERIFICATION FROM PREVIOUS EMPLOYER:

PRE-EMPLOYMENT URINALYSIS

AND BREATH ANALYSIS CONSENT FORM

I UNDERSTAND that as required by the Federal Highway Administration Regulations, Title 49 Code of Federal Regulations, Section 382.301, all driver-applicants of this empoyer must be tested for controlled substances and alcohol as a pre-condition as a pre-condition for employment.

I understand that a verified positive test result for controlled substances and/or an alcohol concentrations of 0.04 or higher will render me unqualified to operate a commercial motor vehicle.

The Medical Review Officer (MRO) will maintain the results of my controlled substance test. Negative and positive results will be reported to the employer. If the results are positive, the controlled substance will be identified.

Alcohol test results will be maintained by the employer.

The results will not be released to any other parties without my written authorization. I understand the above conditions and hereby agree to comply with them.

I consent to the urine sample collection and testing for controlled substances and the breath sample collection/testing for alcohol.

________________________________________________ ______/ ______/ ______

(Applicant’s Name - print) (Month) (day) (year)

X

Previous 7 Days - Statement of On-Duty Hours

ALIMCO LOGISTICS, LLC

(for newly hired & intermittent drivers)

Driver Name __________________________

Date of Hire ___________________________ 1st day Driven: _______________________

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 immediate preceding 7 days and time at which such driver was last relieved from duty prior to beginning work for such Carrier. Rule 305.8(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.

This is a record of the 7 days prior to driving for the above company.

Start with yesterday’s date:

DAY 1 (yesterday) 2 3 4 5 6 7 TOTAL HOURS LAST WEEK DATE HOURS WORKED

I hereby certify that the information given above is correct to the best of my knowledge and belief.

X

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 working for other employers. The definition of on-duty time found in Section 395.2 paragraphs (8) & (9) of the Federal Motor Carrier Safety Regulations includes time performing any other work in the 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.

(circle one)

Are you currently working for another employer Yes or No At this time do you intend to work for another employer

while still employed by this company? Yes or No

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.

Driver Name ___________________

X

Witness: ________________________________ ________________________

Company Representative Date

APPLICATION DRUG CONSORTIUM

PHONE ___________________________ FAX ______________________________ SENIOR MANAGEMENT CONTACT _______________________________________

PARTICIPANT INFORMATION

NAME _____________________________________________ SSN ______________________ ADDRESS __________________________________

CITY _______________________________ ST ___ ZIP ____________

CELL PHONE _________________________ HOME PHONE ____________________________ FIRST DAY OF DRIVING ___________________________ BIRTH DATE _______________________ CDL# ___________________________ ST ________ EXP DATE __________________ CLASS ____

Please enter me into The Safety Department Drug Consortium. I realize that I will be placed into a drug pool in which I may be called at any time to submit to a drug and/or alcohol test in accordance with FMCSA rules and procedures on 49CFR part 382. I agree to submit to a random test whenever I receive notice from The Safety Department and/or my supervisor.

X

Signature of Driver Applicant Date

________________________________________________

Name of Driver (printed)

__________________________________________________________ _________________________________________

CDL Drivers Compliance & Safety Manual

And Drug & Alcohol Info. Packet

Acknowledgement

ALIMCO LOGISTICS

,

LLC

Name of Company

Name of CDL Driver

IMPORTANT!!!! After hired, date of First Day to Drive

This is to certify that I have received this Handbook and will take it upon myself to study and familiarize myself with the contents.