Application for Authorization to Drive



[pic] Norsemen Trucking Inc. [pic]

106 East Main Street

Lake Mills, Iowa 50450

Telephone: 641-592-5060 Fax: 641-592-5066

Application for Authorization to Drive

Please print plainly in ink and all blanks must be completed

Date of Application:___/___/___ Home Phone #: ( )_________ Alt. Phone #: (__)__________

Position Applied for: ____ Company Driver ____Contractor ____Driver for Contractor

____Full-time ____Part-time (Specify what days and hours)____________________________

Name:___________________________________________/______________________________________________

First Middle Last Previously Used Names

Address:_______________________________________________________________________________________

Street City State Zip How Long?

Current Address:_______________________________________________________________________________

Street City State Zip How Long?

List all Previous addresses for past 5 years:

____________________________________________________________________________________________________________________________________

Street City State Zip How Long?

____________________________________________________________________________________________________________________________________

Street City State Zip How Long?

Date of Birth:___/___/___ (if you are applying for a job as a commercial truck driver.)

Incase of an emergency, whom should we contact?

________________________________________________________________________________________________

Name Phone Number Relationship

________________________________________________________________________________________________

Name Phone Number Relationship

Have you ever failed or refused a pre-employment drug/alcohol test given by a company where you never accepted employment? Yes_____ No_____

Have you worked for this company before? Yes_____ No_____ Dates:________________

Reason for leaving: ______________________________________________________________

Did you have any relatives working for this company? Yes______ No______ If yes to this answer:

Name:___________________________________________________Relationship:___________

EMPLOYMENT RECORD FOR THE PAST TEN (10) YEARS

Begin with your present or most recent job and work backward in order, listing your employers for at least 10 years including all full and part time employment. All times must be accounted for including military service, self-employment and periods of unemployment. Use supplementary sheet if necessary.

WE MUST HAVE TELEPHONE NUMBERS. INCLUDE PERIODS OF UNEMPLOYMENT

Are you presently employed? ____Yes ____No May we contact your current Employer? ____Yes ____No

Name:_____________________________ Supervisor:__________________________

Address:__________________________________ Telephone:___________________

City:____________________________State:__________ Zip Code:_______________

Position Held:______________________________Rate of Pay: __________________

Driving Experience: ___ All 48 ___ Midwest ___ South ___ East ___West ___ Northwest ___ Mountains

Equipment Driven: ___ Straight Truck ___Cabover ___Conventional ___Reefer ___Van ___Dump ___Flatbed ___Tanker ___Autohauler ___Doubles Trailer Length:____

Ft. Logbook required:_____ Approximate Total Number of Miles Driven for this Employer:____________

Reason for Leaving: ___Quit ___Fired ___Lay off ___Other ___Explain Circumstances:__________

______________________________________________________________________________________

Were you subject to the Federal Motor Carrier Safety Regulations while employed by this employer? ___Yes ___ No

Was this a safety sensitive function as defined by the DOT subject to alcohol & drug testing? Yes ___No

Name:_____________________________ Supervisor:__________________________

Address:__________________________________ Telephone:___________________

City:____________________________State:__________ Zip Code:_______________

Position Held:______________________________Rate of Pay: __________________

Driving Experience: ___ All 48 ___ Midwest ___ South ___ East ___West ___ Northwest ___ Mountains

Equipment Driven: ___ Straight Truck ___Cabover ___Conventional ___Reefer ___Van ___Dump ___Flatbed ___Tanker ___Autohauler ___Doubles Trailer Length:____

Ft. Logbook required:_____ Approximate Total Number of Miles Driven for this Employer:____________

Reason for Leaving: ___Quit ___Fired ___Lay off ___Other ___Explain Circumstances:__________

______________________________________________________________________________________

Were you subject to the Federal Motor Carrier Safety Regulations while employed by this employer? ___Yes ___ No

Was this a safety sensitive function as defined by the DOT subject to alcohol & drug testing? Yes ___No

Name:_____________________________ Supervisor:__________________________

Address:__________________________________ Telephone:___________________

City:____________________________State:__________ Zip Code:_______________

Position Held:______________________________Rate of Pay: __________________

Driving Experience: ___ All 48 ___ Midwest ___ South ___ East ___West ___ Northwest ___ Mountains

Equipment Driven: ___ Straight Truck ___Cabover ___Conventional ___Reefer ___Van ___Dump ___Flatbed ___Tanker ___Autohauler ___Doubles Trailer Length:____

Ft. Logbook required:_____ Approximate Total Number of Miles Driven for this Employer:____________

Reason for Leaving: ___Quit ___Fired ___Lay off ___Other ___Explain Circumstances:__________

______________________________________________________________________________________

Were you subject to the Federal Motor Carrier Safety Regulations while employed by this employer? ___Yes ___ No

Was this a safety sensitive function as defined by the DOT subject to alcohol & drug testing? Yes ___No

________________________________________________________________________________________________

Name:_____________________________ Supervisor:__________________________

Address:__________________________________ Telephone:___________________

City:____________________________State:__________ Zip Code:_______________

Position Held:______________________________Rate of Pay: __________________

Driving Experience: ___ All 48 ___ Midwest ___ South ___ East ___West ___ Northwest ___ Mountains

Equipment Driven: ___ Straight Truck ___Cabover ___Conventional ___Reefer ___Van ___Dump ___Flatbed ___Tanker ___Autohauler ___Doubles Trailer Length:____

Ft. Logbook required:_____ Approximate Total Number of Miles Driven for this Employer:____________

Reason for Leaving: ___Quit ___Fired ___Lay off ___Other ___Explain Circumstances:__________

______________________________________________________________________________________

Were you subject to the Federal Motor Carrier Safety Regulations while employed by this employer? ___Yes ___ No

Was this a safety sensitive function as defined by the DOT subject to alcohol & drug testing? Yes ___No

Name:_____________________________ Supervisor:__________________________

Address:__________________________________ Telephone:___________________

City:____________________________State:__________ Zip Code:_______________

Position Held:______________________________Rate of Pay: __________________

Driving Experience: ___ All 48 ___ Midwest ___ South ___ East ___West ___ Northwest ___ Mountains

Equipment Driven: ___ Straight Truck ___Cabover ___Conventional ___Reefer ___Van ___Dump ___Flatbed ___Tanker ___Autohauler ___Doubles Trailer Length:____

Ft. Logbook required:_____ Approximate Total Number of Miles Driven for this Employer:____________

Reason for Leaving: ___Quit ___Fired ___Lay off ___Other ___Explain Circumstances:__________

______________________________________________________________________________________

Were you subject to the Federal Motor Carrier Safety Regulations while employed by this employer? ___Yes ___ No

Was this a safety sensitive function as defined by the DOT subject to alcohol & drug testing? Yes ___No

________________________________________________________________________________________________

Name:_____________________________ Supervisor:__________________________

Address:__________________________________ Telephone:___________________

City:____________________________State:__________ Zip Code:_______________

Position Held:______________________________Rate of Pay: __________________

Driving Experience: ___ All 48 ___ Midwest ___ South ___ East ___West ___ Northwest ___ Mountains

Equipment Driven: ___ Straight Truck ___Cabover ___Conventional ___Reefer ___Van ___Dump ___Flatbed ___Tanker ___Autohauler ___Doubles Trailer Length:____

Ft. Logbook required:_____ Approximate Total Number of Miles Driven for this Employer:____________

Reason for Leaving: ___Quit ___Fired ___Lay off ___Other ___Explain Circumstances:__________

______________________________________________________________________________________

Were you subject to the Federal Motor Carrier Safety Regulations while employed by this employer? ___Yes ___ No

Was this a safety sensitive function as defined by the DOT subject to alcohol & drug testing? Yes ___No

Name:_____________________________ Supervisor:__________________________

Address:__________________________________ Telephone:___________________

City:____________________________State:__________ Zip Code:_______________

Position Held:______________________________Rate of Pay: __________________

Driving Experience: ___ All 48 ___ Midwest ___ South ___ East ___West ___ Northwest ___ Mountains

Equipment Driven: ___ Straight Truck ___Cabover ___Conventional ___Reefer ___Van ___Dump ___Flatbed ___Tanker ___Autohauler ___Doubles Trailer Length:____

Ft. Logbook required:_____ Approximate Total Number of Miles Driven for this Employer:____________

Reason for Leaving: ___Quit ___Fired ___Lay off ___Other ___Explain Circumstances:__________

______________________________________________________________________________________

Were you subject to the Federal Motor Carrier Safety Regulations while employed by this employer? ___Yes ___ No

Was this a safety sensitive function as defined by the DOT subject to alcohol & drug testing? Yes ___No

________________________________________________________________________________________________

Name:_____________________________ Supervisor:__________________________

Address:__________________________________ Telephone:___________________

City:____________________________State:__________ Zip Code:_______________

Position Held:______________________________Rate of Pay: __________________

Driving Experience: ___ All 48 ___ Midwest ___ South ___ East ___West ___ Northwest ___ Mountains

Equipment Driven: ___ Straight Truck ___Cabover ___Conventional ___Reefer ___Van ___Dump ___Flatbed ___Tanker ___Autohauler ___Doubles Trailer Length:____

Ft. Logbook required:_____ Approximate Total Number of Miles Driven for this Employer:____________

Reason for Leaving: ___Quit ___Fired ___Lay off ___Other ___Explain Circumstances:__________

______________________________________________________________________________________

Were you subject to the Federal Motor Carrier Safety Regulations while employed by this employer? ___Yes ___ No

Was this a safety sensitive function as defined by the DOT subject to alcohol & drug testing? Yes ___No

________________________________________________________________________________________________

Name:_____________________________ Supervisor:__________________________

Address:__________________________________ Telephone:___________________

City:____________________________State:__________ Zip Code:_______________

Position Held:______________________________Rate of Pay: __________________

Driving Experience: ___ All 48 ___ Midwest ___ South ___ East ___West ___ Northwest ___ Mountains

Equipment Driven: ___ Straight Truck ___Cabover ___Conventional ___Reefer ___Van ___Dump ___Flatbed ___Tanker ___Autohauler ___Doubles Trailer Length:____

Ft. Logbook required:_____ Approximate Total Number of Miles Driven for this Employer:____________

Reason for Leaving: ___Quit ___Fired ___Lay off ___Other ___Explain Circumstances:__________

______________________________________________________________________________________

Were you subject to the Federal Motor Carrier Safety Regulations while employed by this employer? ___Yes ___ No

Was this a safety sensitive function as defined by the DOT subject to alcohol & drug testing? Yes ___No

________________________________________________________________________________________________

Name:_____________________________ Supervisor:__________________________

Address:__________________________________ Telephone:___________________

City:____________________________State:__________ Zip Code:_______________

Position Held:______________________________Rate of Pay: __________________

Driving Experience: ___ All 48 ___ Midwest ___ South ___ East ___West ___ Northwest ___ Mountains

Equipment Driven: ___ Straight Truck ___Cabover ___Conventional ___Reefer ___Van ___Dump ___Flatbed ___Tanker ___Autohauler ___Doubles Trailer Length:____

Ft. Logbook required:_____ Approximate Total Number of Miles Driven for this Employer:____________

Reason for Leaving: ___Quit ___Fired ___Lay off ___Other ___Explain Circumstances:__________

______________________________________________________________________________________

Were you subject to the Federal Motor Carrier Safety Regulations while employed by this employer? ___Yes ___ No

Was this a safety sensitive function as defined by the DOT subject to alcohol & drug testing? Yes ___No

Please answer the following questions with a “Yes” or “No”

1. Are you a U.S. Citizen or otherwise lawfully authorized to work in this country? ___Yes ___No

2. Have you ever been convicted of a felony? ___Yes ____No

3. Is there any reason that you might be unable to perform the functions of the job, for which you have applied, (Truck Driver), i.e.: but not limited to lifting, loading, unloading, minor maintenance, tarping and securement of loads, fueling, and driving? ___Yes ___No

If yes, explain;__________________________________________________________________________

4. Have you been convicted for driving while intoxicated or driving while under the influence of drugs within the last five (5) years? ___Yes ___No

5. Are you familiar with the Federal Motor Carrier Safety Regulations? ___Yes ___No

6. Have you ever been denied a bond? ___Yes ___No

7. Have you ever had your driver’s license suspended or revoked? ___Yes ___No

Licensing Information (Must have a valid CDL) List all licenses held the past 5 years

|Issuing State |License Number |Type |Expiration Date |Restrictions |Turned In? |

| | | | | | |

| | | | | | |

| | | | | | |

Driving Record

Have you been convicted of any traffic violations in the past 4 years? ___Yes ___No

List all traffic violations except for parking tickets for the last 4 years. If none, write “None”.

|Month/Year |Violation |Type of Vehicle |Location, City/State |Penalty/Fine |Points Assessed |

| | | | | | |

| | | | | | |

| | | | | | |

| | | | | | |

| | | | | | |

Accidents

Have you been involved in any accidents in the past 4 years? ___Yes ___No

List all accidents, preventable, non-preventable, regardless of $$ amount or fault in the past 4 years. If none, write “None.”

|Month/Year|Type of |Type of |Location, |$$ Amount of |Number of |Number of |Were you |Were you at |

| |accident |Vehicle |City/State |Damages |Fatalities |Injuries |ticketed |fault |

| | | | | | | | | |

| | | | | | | | | |

| | | | | | | | | |

| | | | | | | | | |

| | | | | | | | | |

Cargo Claims

Have you had any cargo claims in the past 4 years? Yes No

List all claims, preventable, non-preventable, regardless of $$ amount or fault in the past 4 years. If none, write “None.”

|Month/Year |Type of Claim |$$ Amount of Claim |Type of Cargo |Were you charged |

| | | | |for the claim |

| | | | | |

| | | | | |

| | | | | |

Education

Circle highest grade completed: 1 2 3 4 5 6 7 8 9 10 11 12 College: 1 2 3 4 5 6 7 8

Check the following that apply: ___High School Diploma ___G.E.D. ___College Degree ___None of these

List any Truck Driving Schools you have attended, dates of completion, and other safety training:

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Experience and Qualifications

Driving Positions

Do you have a current DOT Medical Card? ______

Do you have full knowledge of DOT Safety Requirements?_____

Have you ever been disqualified from driving for any of the following:

1. Driving a commercial motor vehicle with a blood alcohol concentration of 0.04 or more? Yes ( ) No ( )

2. Driving under the influence of alcohol, as defined by State law? Yes ( ) No ( )

3. Refusing to submit to an alcohol test at the direction of federal, State or local officials? Yes ( ) No ( )

4. Driving a motor vehicle with a gross vehicle weight rating of 10,001 pounds or more while under the influence of an illegal drug (including the improper use of prescription drugs)? Yes ( ) No ( )

5. Transporting, possessing or using illegal drugs (including the improper use of prescription drugs) while on duty? Yes ( ) No ( )

6. Leaving the scene of an accident while operating a commercial motor vehicle? Yes ( ) No ( )

7. Committing a felony involving the use of a motor vehicle with a gross vehicle rating of 10,001 pounds or more? Yes ( ) No ( )

Have you tested positive in a DOT required drug or alcohol test in the past two years, or refused a test for an employer who did not hire you? Yes ( ) No ( ) If yes, provide details on a separate sheet of paper.

I hereby acknowledge that prior to submitting this application, I have been informed that the information provided herein may be used to conduct current and previous employer’s references or any other individuals this Company considers necessary.

I hereby authorize my current and previous employers, references, and any other individuals contacted by this company to release any past or present information requested, including but not limited to past drug and alcohol test results, and I release all providers of said information from any liability stemming from release of same information.

In connection with my application for employment with this Company, I understand that I have the right to review, correct or rebut any information obtained from former employers requested by this Company.

I understand that any false, misleading, or incomplete answers or statements shall be considered sufficient cause for denial or termination of employment and/or authorization to drive.

I understand that nothing contained in this application or in the granting of an interview or a road test is intended to create an employment contract between this Company and myself, for either employment, authorization to drive, or for the providing of any benefits. No promises regarding employment or authorization to drive have been made to me, and no such promises exist unless specifically made by this Company in writing. If an employment relationship is established, I understand that, as an employee at will, I have the right to terminate my employment at any time, and this Company has the same right.

______________________________________________________________________________

Print Name Social Security Number

______________________________________________________________________________

Applicants Signature Date

SAFETY PERFORMANCE HISTORY RECORDS REQUEST Part 2

Instructions: Complete the Safety Performance History Records Request

Part 1 Section 1: Prospective employee Part 2 Sections 3: Previous Employer Complete the information required in this section Complete the information required in this section

Sign and Date Sign and Date

Submit to Prospective Employer Return to Prospective Employer

Part 2 Sections 4: Prospective Employer

Complete the information

Send to Previous Employer Part 2 Section 4a: Prospective Employer

Record receipt of information

Part 1 Section 2: Previous Employer Retain the form

Complete the information requested in this section

Sign and Date

DRIVER/APPLICANT SAFETY PERFORMANCE HISTORY RECORDS REQUEST

This request is made by the driver/applicant in compliance with DOT regulation; 391.23 Investigations and inquiries, paragraphs (I)(1) & (2)

|Section 1 Completed by the Driver/Applicant |

| |

|To: Prospective Employer: ________________________________________________________________ |

| |

|Address: ________________________________________________________________ |

| |

|City, State, Zip Code: _________________________________________________________________ |

| |

| |

|From: Driver/Applicant: ___________________________Social Security/ID #:____________________ |

| |

|Address: _______________________________________________________________ |

| |

|City, State, Zip Code: __________________________________Phone Number_________________ |

| |

| |

| |

|I am submitting this written request for copies of my Department of Transportation Safety Performance History for the preceding three (3) years. I |

|understand for records requested from a prospective employer, that I must arrange to pick up or receive the requested records within thirty (30) days of the |

|records being made available or I have waived my request to review the records. |

| |

|This information should be: ____Mailed to me at the above address ____I will pick up (Will not be given to any other party) |

| |

|Driver/Applicant:_________________________________________________ Date:______/______/_______ |

|Signature month day year |

|Section 2: Completed by the Prospective Employer |

| |

|The information must be provided to the applicant within five (5) business days of receiving the written request. IF the prospective employer has not yet |

|received the requested information from the previous employer(s), then the five business days deadline will begin when the prospective employer receives the |

|requested safety performance history information. |

| |

|Information Supplied to: |

| |

|Name:___________________________________________ Comments:__________________________________ |

| |

|Address:_________________________________________ __________________________________________ |

| |

|City, State, Zip Code:_______________________________ __________________________________________ |

| |

|By: |

| |

|_____________________________________________________ ________________________ Release Date:_____/______/______ |

|Signature of person providing the information Telephone Number MM DD YY |

Applicant Must Read, Initial, Sign and Date

This certifies that I completed this application, and that all entries on it and information in it are true and complete. I hereby certify that I have read and fully understand this application. Prior to signing below, I had the opportunity to ask Norsemen Trucking, Inc. about, and clarify any questions I might have had concerning this application form. ________________(Initial)

I affirm that I have a genuine intent and no other purpose in applying for a job with this company. I hereby certify that the answers given by me on this application form are all true and correct. I understand and agree that any misrepresentations or intentional omissions made by me on this application, on other documents used by Norsemen Trucking, Inc. in support of this application, and/or made during any interviews conducted in conjunction with my application for a position, will be sufficient reason to render me ineligible or result in my subsequent termination by Norsemen Trucking, Inc. at any time, and I understand and agree that the denial of position or my termination for such grounds shall be without liability to Norsemen Trucking, Inc. I also understand that if hired, I will be on a six (6) month probation and may be disqualified and subsequently terminated without recourse. ________________ (Initial)

I authorize Norsemen Trucking, Inc. to make such investigations and inquiries of my personal references, past employment, driving record (when job related), education, criminal record, including character and general reputation and/or other job related matters as may be necessary in arriving at an employment decision. I hereby release employers, supervisors, educational institutions, or other persons from all liability in responding to inquiries in connection with my application. I authorize a copy or facsimile of this form to be as valid as the original. _________________(Initial)

I understand Norsemen Trucking, Inc. does not enter into employment contracts with employees, and that this application does not constitute a job offer, either expressed or implied. Norsemen Trucking, Inc. does not guarantee a position, and that an employment contract is not created in the event I may be eventually offered a position. Further, I understand and agree that no representative of Norsemen Trucking, Inc. has the authority to enter into any agreement, either expressed or implied, or commit to the utilization of my services for any specified period of time. _________________(Initial)

I understand and agree that this application is limited to the specific position for which I am applying, and that it will remain in an active status for a period ninety (90) days from that application date, and that if I am not offered the position for which I am applying within the ninety (90) day period of this application, I will not be considered for other positions or openings. I understand that I may reapply with Norsemen Trucking, Inc. under the same conditions, by completing and submitting a new application. ____________________(Initial)

I understand also, that I will be expected to, and agree to abide by all work and safety rules of the Company as required or permitted by law. I understand and agree that my failure to abide by any rule will be sufficient reason for my termination by Norsemen Trucking, Inc. at any time, and I understand and agree that my termination for such ground shall be without liability to Norsemen Trucking, Inc. _______________(Initial)

I understand and fully agree that this application is limited to the specific position for which I am applying. I understand and agree that in order to be offered a position, I must be able to perform the essential functions of the job (without, or with reasonable accommodation as may be required). ____________(Initial)

______________________________________________________________________________________

Applicant Signature Date

-----------------------

Applications are held for 90 days. Applications are considered for position without regard to race, creed, color, sex, religion, age (other than minimum requirements), disability, marital status or national origin

SS#____/___/______ Drivers License#______________________ State_________ Class______

Previous Employer

Dates of Employment:

To:_____________

From:___________

2nd to last Employer

Dates of Employment:

To:_____________

From:___________

3rd to last Employer

Dates of Employment:

To:_____________

From:___________

4th to last Employer

Dates of Employment:

To:_____________

From:___________

5th to last Employer

Dates of Employment:

To:_____________

From:___________

6th to last Employer

Dates of Employment:

To:_____________

From:___________

7th to last Employer

Dates of Employment:

To:_____________

From:___________

8th to last Employer

Dates of Employment:

To:_____________

From:___________

9th to last Employer

Dates of Employment:

To:_____________

From:___________

10th to last Employer

Dates of Employment:

To:_____________

From:___________

Safety Performance History Records Request Part 1

Section 1: To be completed by prospective Employee

I, (print name) ___________________________________________ Social Security Number:_________________

Hereby authorize: Date of Birth:_________________________

Previous Employer:__________________________________ Phone #:_________________ Fax:_____________

Address:______________________________________________ City, State, Zip:__________________________

To release and forward the information requested by section 3 of this document concerning my Alcohol and Controlled Substance Testing records within the previous 3 years from: (applicant date) _______________________

To:

Prospective Employer:________________________________________ Phone #:__________________________

Attention:________________________________________

Address:______________________________________________ City, State, Zip:__________________________

In compliance with §40.25(g) and §391.23(h), release of this information must be made in a written form that ensures confidentiality such as fax, email or letter.

Prospective employer’s confidential fax number:_____________________________________

Prospective employers confidential email address:____________________________________

Applicants Signature:______________________________________ Date:________________________________

This information is being requested in compliance with §40.25(g) and §391.23(h)

Section 2: To be completed by Previous Employer

Accident History

(1) The applicant named above was employed by us. ____Yes ____No

Employed as ______________________________ from (M/Y)________________ to (M/Y)_________________

If driver was involved in a safety sensitive position subject to controlled substance and alcohol testing under part 40, check here. []

Did he/she drive motor vehicles for you? ____Yes ____No If yes, what type? __Straight Truck __Tractor-Semi Trailer __Bus __Tanker __Doubles/Triples __Other (specify):_________________________________________________________

(2) Reason for leaving your employment: ____Discharged ____Resignation ____Lay off ____Military Duty

If there is no safety performance history to report, check here [] sign below and return.

Accidents: Complete the following for any accidents included on your accident register (390.15(b)) that involved the applicant in the 3 years prior to the application date shown above or check here [] if there is no accident register data for this applicant.

Date Location # of Injuries # of Fatalities Hazmat Involved

_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Please provide information concerning any other accidents involving the applicant that were reported to government agencies or insurers or retained under internal company policies: ____________________________________________________________ _______________________________________________________________________________________________________

Any other remarks:_______________________________________________________________________________________

_______________________________________________________________________________________________________

Signature:_____________________________________ Title:_________________________ Date:_____________________

Safety Performance History Records Request Part 2

Section 3: To be completed by Previous Employer

If the driver was not subjected to DOT testing requirements while employed by this employer, please check here [], fill in the dates of employment from ______________ to_____________, complete bottom of section 3, sign and return.

Driver was subject to DOT testing requirements from_______________________ to________________________.

1. Has this person had an alcohol test with a result of 0.04 or higher alcohol concentrations? ____Yes ____No

2. Has this person tested positive or adulterated or substituted a test specimen for controlled substances? ____Yes ____No

3. Has this person refused to submit to post-accident, random, reasonable suspicion or follow-up alcohol controlled substance test? ____Yes ____No

4. Has this person committed other violations of subpart B or Part 382 or part 40? ____Yes ____No

5. If this person has violated a DOT drug and alcohol regulation, did this person complete a SAP

prescribed rehabilitation program in your employ, including return-to-work and follow-up tests? If yes, please send documentation back with this form. ____Yes ____No

6. For a driver who successfully completed a SAP’s rehabilitation referral and remained in you r employment, did this driver subsequently have 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 drug and alcohol testing information obtained from previous employers in the previous 3 years prior to the application date on Part 1.

Name:_________________________________________________________________________________________________

Company:______________________________________________________________________________________________

Address:______________________________________________________ City, State, Zip:____________________________

Section 3 Completed by (signature):___________________________________________________ Date:_____________________________

Section 4: To be completed by Prospective Employer

This form was (checked one): ____Faxed to Previous Employer ____Mailed ____Emailed ____Other:_____________________

By:______________________________________________________________________________ Date:__________________________

Section 4a: To be completed by Prospective Employer

Complete below when information is obtained.

Information obtained from:_________________________________________________________________________________

Recorded by:____________________________________________ Method: ____Fax ____Mail ____Email ____Telephone

Date:___________________________________________________ Other__________________________________________

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