DRIVER QUALIFICATION PACKET

DRIVER QUALIFICATION PACKET
The attached documents are provided to you to illustrate compliance with the USA laws that came into effect October 29, 2004 in the Federal Motor Carrier Safety Regulations (FMCSRThey are distributed to you as a sample, for illustration purposes only.

This packet is not meant as an all-inclusive list of required items; consult Federal Motor Carrier Safety Regulations (FMCSRs) Parts 40, 382 and 391, Canada’s National Safety Code and appropriate Provincial Acts.

· DRIVER HIRING & QUALIFICATION RECORDS CHECKLIST: (Revised 6/11)Formis used to document driver file requirements per FMCSR 391 and renewal dates for these items. · APPLICATION FOR QUALIFICATION: (Revised 2011/06) Required by FMCSR391.21. This application is suitable for independent owner/operators or company employees/drivers. NOW includes Driver’s Rights under 391.23. · REQUEST FOR DRIVER’S SAFETY PERFORMANCE HISTORY: (NEW 9/04) As required by FMCSR 391.21 for past employment investigation. · FOURTEEN-DAY PRIOR LOG FORM: FMCSR 395.3. requirement is for previous 7days, however, best practice in Canada is for previous 14 days · DRIVER PERFORMANCE EVALUATION {Road Test} (Revised 9/04) Should be usedto summarize the evaluator’s thoughts on driver performance, including skills performed particularly well, those needing improvement and why. Includes: · CERTIFICATION OF ROAD TEST As required per FMCSR Subpart D391.31. · VIOLATION AND ANNUAL REVIEW RECORD: Allows review of driver’srecordas required by FMCSR 391.25 and 391.27.

· DRIVER “INVESTIGATION HISTORY” FILE CHECKLIST (NEW 9/04) FMCSR

requires this form to be filed in a secure location, with limited access.

The following documents should be placed in Personnel and/or Confidential File.
· DRIVER APPLICANT AND ALCOHOL PRE-EMPLOYMENT STATEMENT: (NEW)
Form used to document an applicant applying for a safety sensitive function, as required per CFR 40.25(j

· CONTROLLED SUBSTANCE & ALCOHOLTESTINGINFORMATION
ACKNOWLEDGMENT/ CONSENT FORM: (NEW 9/04) As required by FMCSR 382.301. [Page 1, drug & alcohol information, needs to be kept in Confidential File.]
APPLICATION FOR QUALIFICATION
Carrier Name
Carrier Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Carrier Contact Person

First Name Last Name
Carrier Contact Person Phone Number

Area Code Phone Number
Carrier Confidential Fax Number

Area Code Phone Number
The purpose of this application is to determine whether or not the applicant is qualified to operate motor carrier equipment according to the requirements of the Federal Motor Carrier Safety Regulations and the Company named above.
Instructions:
1. Please print clearly. 2. Complete all sections. If the answer to any question is “No” or “None,” do not leave the item blank, or “None.”
SECTION A - APPLICANT INFORMATION
Name (First, Middle, Last) *

First Name Middle Name Last Name
Date of birth *

Month Day Year
Date
Phone Number *

Area Code Phone Number
Alternative Phone Number

Area Code Phone Number
Email
example@example.com
Position Applying for (check one) *

Driver Contractor Contractor’s Driver Other specify Contractor Contractor's Driver
Residence history for the past three (3) years, beginning with your current address.
Current Address (no., street) *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Date FROM *

Month Day Year
Date
Date TO *

Month Day Year
Date
Address (P1)

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
From:

Month Day Year
Date
To:

Month Day Year
Date
Address (P2)

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
From:

Month Day Year
Date
To:

Month Day Year
Date
Address (P3)

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
From:

Month Day Year
Date
To:

Month Day Year
Date
Have you ever worked for this company before? *

Yes No
If so From:

Month Day Year
Date
To:

Month Day Year
Date
Reason for leaving?
Please indicate the highest grade level completed: *
SECTION B – EMPLOYMENT HISTORY
Please provide a complete record of all employment (starting with the current or most recent) for the past three (3) years, including any unemployment or self-employment. Please also provide all commercial driving experience for the past ten (10) years.
Current or Most Recent Company Name (1)
Position Held
Phone Number

Area Code Phone Number
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
From

Month Day Year
Date
To

Month Day Year
Date
Reason for leaving?
Were you subject to the FMCSRs* while employed here?

Yes No
Was your job designated as a safety-sensitive function in any DOT- regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40?

Yes No
Company Name (2)
Position Held
Phone Number

Area Code Phone Number
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
From

Month Day Year
Date
To

Month Day Year
Date
Reason for leaving?
Were you subject to the FMCSRs* while employed here?

Yes No
Was your job designated as a safety-sensitive function in any DOT- regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40?

Yes No
Company Name (3)
Position Held
Phone Number

Area Code Phone Number
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
From

Month Day Year
Date
To

Month Day Year
Date
Reason for leaving?
Were you subject to the FMCSRs* while employed here?

Yes No
Was your job designated as a safety-sensitive function in any DOT- regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40?

Yes No
Company Name (4)
Position Held
Phone Number

Area Code Phone Number
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
From

Month Day Year
Date
To

Month Day Year
Date
Reason for leaving?
Were you subject to the FMCSRs* while employed here?

Yes No
Was your job designated as a safety-sensitive function in any DOT- regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40?

Yes No
*The Federal Motor Carrier Safety Regulations (FMCSRs) apply to anyone who operates a motor vehicle on a highway in interstate commerce to transport passengers or property when the vehicle: (1) has a GVWR or weighs 10,001 pounds or more; (2) is designed or used to transport nine or more passengers; or (3) is of any size, used to transport hazardous materials in a quantity requiring placarding.
SECTION C – DRIVING HISTORY/EXPERIENCE
Do you have STRAIGHT Truck experience? *

Yes No
If YES, From Date

Month Day Year
Date
To Date

Month Day Year
Date
Approximate Miles of STRAIGHT Truck Experience
Do you have TRACTOR TRAILER experience? *

Yes No
If YES, From Date

Month Day Year
Date
To Date

Month Day Year
Date
Approximate Miles of TRACTOR TRAILER Experience
Do you have LCV (LONG COMBINATION VEHICLE) experience? *

Yes No
If YES, From Date

Month Day Year
Date
To Date

Month Day Year
Date
Approximate Miles of LCV (LONG COMBINATION VEHICLE) Experience
Do you have any OTHER experience?

No
If YES, From Date

Month Day Year
Date
To Date

Month Day Year
Date
Approximate Miles of "OTHER" Experience
Place a "Checkmark" at each Province or State operated in for the last five (5) years.

Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Ontario Prince Edward Island Quebec Saskatchewan Northwest Territories Nunavut Yukon Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
List special courses/training completed (PTD/DDC, Dangerous Goods, etc)
List any SAFE Driving Awards you hold and from whom.
Have you been involved in an accident or collision in the past three (3) years? *

Yes, see below No, I have not been in any accidents, or collisions in the past three (3) years
Nature of Collision (1)
Date

Month Day Year
Date
Location
Number of Fatalities?
Number of Injured People?
Nature of Collision (2)
Date

Month Day Year
Date
Location
Number of Fatalities?
Number of Injured People?
Nature of Collision (3)
Date

Month Day Year
Date
Location
Number of Fatalities?
Number of Injured People?
Have you had any traffic convictions or forfeitures in the past three (3) years (other than parking violations)? *

Yes, see below No, I have not been in any traffic convictions or forfeitures in the past three (3) years
Offence (1)
Date

Month Day Year
Date
Location
Penalty
Offence (2)
Date

Month Day Year
Date
Location
Penalty
Offence (3)
Date

Month Day Year
Date
Location
Penalty
Driver’s License (List each driver’s license held in the past three years)
Current Driver Licence PROVINCE *
Current Driver Licence Number *
Type/Class *
Endorsement(s) Current Licence *
Expiry Date Of Current Licence *

Month Day Year
Date
PROVINCE Past Driver's Licence (1)
Driver Licence Number
Type/Class
Endorsement(s)
Expiry Date

Month Day Year
Date
PROVINCE Past Driver's Licence (2)
Driver Licence Number
Type/Class
Endorsement(s)
Expiry Date

Month Day Year
Date
Have you ever been denied a license, permit or privilege to operate a motor vehicle? *

Yes, see below No
YES, Here are the details.
Has any license, permit or privilege ever been suspended or revoked? *

Yes, see below No
YES, Here are the details.

Personal References-List three (3) persons for references, other than family members, who have knowledge of your safety habits.

	Name	Address	Telephone
Reference (1)
Reference (2)
Reference (3)

To Be Read and Signed by Applicant
This certifies that I completed this application form and that all entries on it and information in it are true and complete to the best of my knowledge. It is agreed and understood that any misrepresentation given on this application or interview(s) shall be considered an act of dishonesty and may result in a discharge. It is agreed and understood that the motor carrier or his agents may investigate the applicant's background to ascertain any and all information of concern to applicant's record, whether same is of record or not, and applicant releases employers and persons named herein from all liability for any damages on account of his furnishing such information.

I agree to furnish such additional information and complete such examinations as may be required to complete my application file. It is agreed and understood that this Application for Qualification in no way obligates the motor carrier to employ or hire the applicant. It is agreed and understood that if qualified and hired, I may be on a probationary period during which time I may be disqualified without recourse.

I understand that from time to time the company will furnish my personal information as necessary to third parties such as insurance companies and brokers. The company agrees to collect, use and disclose such information only in a manner that a reasonable person would consider appropriate in the circumstances, and that would be in compliance with the Protection of Personal Information and Electronic Documents Act (PIPEDAThe company further agrees to safeguard the security of such information in a manner appropriate to the sensitivity of such information, and in compliance with PIPEDA.
I agree to supply the following information as part of this application *

Driver’s MVR Abstract (current to the past 30 days) Driver’s CVOR Abstract (Ontario & Alberta only, current to the past 30 days) Criminal Record Search (current to the past 90 days)
Signature *

Clear
Date *

Month Day Year
Date

DRIVER APPLICANT DRUG AND ALCOHOL PRE-EMPLOYMENT STATEMENT
CFR Part 40.25(j) requires the employer to ask any applicant, 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 rules during the past two years. If the potential employee admits that he or she had a positive test or refusal to test, we must not use the employee to perform safety-sensitive function, until and unless, the potential employee provides documentation of successful completion of the return-to-duty process. (See Section 40.25(b5) and (e
Name

First Name Middle Name Last Name
ID Number:
As an applicant, applying to perform safety-sensitive functions for our company, you are required by CFR Part 40.25(j) to respond to the following questions. *

YES, I have you tested positive, or refused to test, on any pre-employment drug or alcohol test administered by an employer to which you applied for, but did not obtain, safety-sensitive transportation work covered by DOT agency drug and alcohol testing rules during the past two years? NO
If you answered yes, to the above question, can you provide proof that you have successfully completed the DOT return-to-duty requirements?

YES, I have proof. NO
My signature below certifies that the information provided is true and correct.
Applicant's Signature: *

Clear
Date: *

Month Day Year
Date
CONTROLLED SUBSTANCE & ALCOHOL TESTING INFORMATION ACKNOWLEDGEMENT/CONSENT FORM
As a condition of employment with {carrierName}, Commercial Motor Vehicle (CMV) Driver Applicants must submit to a pre-employment controlled substances test as required by the Federal Motor Carrier Safety Regulations (FMCSR) Section 382.301. A motor carrier must receive verified negative test results for the applicant driver for the applicant to be eligible for employment.

If you are hired, you will be subject to laws requiring additional controlled substances and alcohol testing on you under numerous situations including, but not limited to, the following: Post-Accident – Section 382.303, Random– Section 382.305, Reasonable Suspicion – Section 382.307, Return to Duty – Section 382.309, Follow-up – Section 382.311

A driver, who tests positive to a controlled substance and/or alcohol test, will be immediately removed from a safety-sensitive position as required by Part 382 of the FMCSR. Federal law prohibits a Driver from returning to a safety-sensitive position for any motor carrier until and unless the Driver completes the Substance Abuse Professionals (SAP) evaluation, referral and educational/treatment process, as described in FMCSR Part 40, Subpart O.

All controlled substances and alcohol testing will be conducted in accordance with Parts 40 and 382 of the FMCSR.

I {namefirst} {namemiddle} {namelast}, have read the above-controlled substances and alcohol testing requirements and understand them.
Signature *

Clear
Date *

Month Day Year
Date
Original to be retained on file - Copy to Driver Applicant

DRIVER’S RIGHTS PERTAINING TO RELEASE OF DRIVER INFORMATION UNDER REGULATION 391.23
Motor carriers have the responsibility to make the following investigations and inquiries with respect to each driver employed, other than a person who has been a regularly employed driver of the motor carrier for a continuous period, which began before January 1, 1971.

a) (1) An inquiry into the driver’s driving record during the preceding three years to the appropriate agency of every State in which the driver held a motor vehicle operator’s license or permit during those three years; and (2) An investigation of the driver’s employment record during the preceding three years.

b) A copy of the driver record(s) obtained in response to the inquiry or inquiries to each State driver record agency, as required. This must be placed in the Driver Qualification File within 30 days of the date the driver’s employment begins and be retained in compliance with 391.51.

c) Replies to the investigations of the driver’s safety performance history must be placed in the Driver Investigation History File within 30 days of the date the driver’s employment begins. This is effective as of October 30, 2004.

d) Prospective motor carrier must investigate the information from all previous employers of the applicant that employed the driver to operate a CMV within the previous three years. This information must cover general driver identification and employment verification information, data elements as specified in 390.15 for any accidents involving the driver that occurred in the three-year period preceding the date of the employment application, and any accidents the previous employer may wish to provide.

e) Prospective motor carrier must investigate the information from all previous DOT regulated employers that employed the driver within the previous three years from the date of the employment application in a safety-sensitive function that required alcohol and controlled substance testing specified by 49 CFR Part 40.

Drivers have the following rights:

1. The right to review information provided by previous employers;

2. The right to have errors in the information corrected by the previous employer and for that previous employer to re-send the corrected information to the prospective employer; and

3. The right to have a rebuttal statement attached to the alleged erroneous information, if the previous employer and the driver cannot agree on the accuracy of the information.

Drivers who wish to review previous employer-provided investigative information must submit a written request to the prospective employer when applying or as late as 30 days after employed or being notified of denial of employment. The prospective employer must provide this information to the applicant within five business days of receiving the written request. If the driver has not arranged to pick up or receive the requested records within 30 days of the prospective employer making them available, the prospective motor carrier may consider the driver to have waived his/her request to review the records. Drivers wishing to request correction of erroneous information in records must send the request for the correction to the previous employer that provided the records. After October 29, 2004, the previous employer must either correct and forward the information to the prospective motor carrier employer or notify the driver within 15 days of receiving the driver’s request to correct the data that it does not agree to correct the data. Drivers wishing to rebut information in records must send the rebuttal to the previous employer with instruction to include the rebuttal in the driver’s Safety Performance History.

I acknowledge that I have read and understand the contents of this document.
Signature *

Clear
Date *

Month Day Year
Date
Driver's Name

First Name Middle Name Last Name

Driver’s Safety Performance History & Information from DOT Regulated Previous Employer(s)
NOTES:

1. If this information is not available from the previous employer, you as a prospective employer must get this information from the Driver/Applicant.

2. Drug and Alcohol information must be kept in a separate Personnel and/or Confidential file.
Carrier Name
Carrier Contact Person

First Name Last Name
Carrier Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number

Area Code Phone Number
Confidential Fax Number

Area Code Phone Number
Driver to complete this section

As a Commercial Motor Vehicle (CMV) Driver, I understand that per the Federal Motor Carrier Safety Regulations (FMCSRs) Part 391.21, the following information will be requested from all previous Employers for which I operated a CMV, subject to the FMCSR Parts 390 and/or 40, 382 & 383, within the past three years, from date shown below. I also acknowledge that this information will be used in determining my eligibility to be hired, that I have the right to review this information and rebut any errors in these statements from my prior employers, as described in the FMCSR Part 391.23.
I, {namefirst} {namemiddle} {namelast}, hereby authorize this Company to release all records of employment, including assessments of my job performance, ability and fitness (including dates of any and all alcohol or drug tests, those confirmed results and/or my refusal to submit to any alcohol or drug tests and any rehabilitation completion under direction of (SAP/MRO) to each and every company (or their authorized agents) which may request such information in connection with my application for employment with said company. I hereby release this company, and its employees, officers, directors, and agents from any and all liability of any type as a result of providing information to the above-mentioned person and/or company.
Previous Employer (1)
PE (1) Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number

Area Code Phone Number
Dates of Employment FROM (PE1)

Month Day Year
Date
TO (PE1)

Month Day Year
Date
Date of Birth

Month Day Year
Date
Signature

Clear
Date

Month Day Year
Date
SECTION I – DRUG & ALCOHOL INFORMATION
Please remember to retain a copy for your records. Your timely response is appreciated.
MANDATORY USE FOR ALL ACCOUNT HOLDERS
IMPORTANT NOTICE
REGARDING BACKGROUND REPORTS FROM THE PSP Online Service
1. In connection with your application for employment with {carrierName}, Prospective Employer, its employees, agents or contractors may obtain one or more reports regarding your driving, and safety inspection history from the Federal Motor Carrier Safety Administration (FMCSA).

When the application for employment is submitted in person, if the Prospective Employer uses any information it obtains from FMCSA in a decision to not hire you or to make any other adverse employment decision regarding you, the Prospective Employer will provide you with a copy of the report upon which its decision was based and a written summary of your rights under the Fair Credit Reporting Act before taking any final adverse action. If any final adverse action is taken against you based upon your driving history or safety report, the Prospective Employer will notify you that the action has been taken and that the action was based in part or in whole on this report.

When the application for employment is submitted by mail, telephone, computer, or other similar means, if the Prospective Employer uses any information it obtains from FMCSA in a decision to not hire you or to make any other adverse employment decision regarding you, the Prospective Employer must provide you within three business days of taking adverse action oral, written or electronic notification: that adverse action has been taken based in whole or in part on information obtained from FMCSA; the name, address, and the toll free telephone number of FMCSA; that the FMCSA did not make the decision to take the adverse action and is unable to provide you the specific reasons why the adverse action was taken; and that you may, upon providing proper identification, request a free copy of the report and may dispute with the FMCSA the accuracy or completeness of any information or report. If you request a copy of a driver record from the Prospective Employer who procured the report, then, within 3 business days of receiving your request, together with proper identification, the Prospective Employer must send or provide to you a copy of your report and a summary of your rights under the Fair Credit Reporting Act.

The Prospective Employer cannot obtain background reports from FMCSA unless you consent in writing.

If you agree that the Prospective Employer may obtain such background reports, please read the following and sign below:

2. I authorize {carrierName} to access the FMCSA Pre- Employment Screening Program (PSP) system to seek information regarding my commercial driving safety record and information regarding my safety inspection history. I understand that I am consenting to the release of safety performance information including crash data from the previous five (5) years and inspection history from the previous three (3) years. I understand and acknowledge that this release of information may assist the Prospective Employer to make a determination regarding my suitability as an employee.

3. I further understand that neither the Prospective Employer nor the FMCSA contractor supplying the crash and safety information has the capability to correct any safety data that appears to be incorrect. I understand I may challenge the accuracy of the data by submitting a request to https://dataqs.fmcsa.dot.gov. If I am challenging crash or inspection information reported by a State, FMCSA cannot change or correct this data. I understand my request will be forwarded by the DataQs system to the appropriate State for adjudication.

4. Please note: Any crash or inspection in which you were involved will display on your PSP report. Since the PSP report does not report, or assign, or imply fault, it will include all Commercial Motor Vehicle (CMV) crashes where you were a driver or co-driver and where those crashes were reported to FMCSA, regardless of fault. Similarly, all inspections, with or without violations, appear on the PSP report. State citations associated with FMCSR violations that have been adjudicated by a court of law will also appear, and remain, on a PSP report.

I have read the above Notice Regarding Background Reports provided to me by Prospective Employer and I understand that if I sign this consent form, Prospective Employer may obtain a report of my crash and inspection history. I hereby authorize Prospective Employer and its employees, authorized agents, and/or affiliates to obtain the information authorized above.
Signature

Clear
Date

Month Day Year
Date
Name

First Name Middle Name Last Name
FOURTEEN-DAY PRIOR LOG FORM
(Data sheet for new, casual, or temporary drivers)
Name

First Name Middle Name Last Name
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number

Area Code Phone Number
DRIVER'S LICENSE #:
Province:
Instructions: At the time of initial employment as a driver, or when being employed occasionally, the regulations of the Department of Transportation [Section 395.8 (j2)] require the motor carrier to obtain from you a signed statement giving the total time on duty during the immediately preceding 7 days and the time at which you were last relieved from duty prior to beginning work for the motor carrier. In the spaces below, show the number of hours worked (on duty) in each of the last 7 days. For Canadian drivers please enter each of the last fourteen days.

14 Days

	Date (Day/Month/Year)	On-Duty Hours
Day 1
Day 2
Day 3
Day 4
Day 5
Day 6
Day 7
Day 8
Day 9
Day 10
Day 11
Day 12
Day 13
Day 14

Total Number of On-Duty Hours in the last Fourteen (14) days?
I hereby certify that the information given above is correct to the best of my knowledge and belief and that I was last relieved from work at:
Time that I was last relieved from work?

: Hour Minutes AM/PM Option
Date that I was last relieved from work?

Month Day Year
Date
Driver's Signature

Clear
Today's Date:

Month Day Year
Date
VIOLATION AND ANNUAL REVIEW RECORD
Name

First Name Middle Name Last Name
I certify that the following is a true and complete list of traffic violations (other than parking violations) for which I have been convicted or forfeited bond or collateral during the past 12 months.
If NO Violations in the past twelve (12) months, check "NONE"

NONE

Certification of Violations

	Date	Offence	Location	Type of Vehicle Operated
Offence 1
Offence 2
Offence 3

If NO violations are listed above, I certify that I have not been convicted or forfeited bond or collateral on account of any violation required to be listed during the past 12 months.
(Driver's Signature)

Clear
(Date of Certification)

Month Day Year
Date
Carrier Name
Carrier Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
ANNUAL REVIEW AND EVALUATION OF DRIVER’S RECORD
In accordance with Section 391.25, Motor Carrier Safety Regulations, all information pertinent to the driver’s safety of operations, including the list of violations furnished by him in accordance with Section 391.27, has been reviewed for the past 12 months.

ACTION TAKEN
Carrier Name
Carrier Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Should be Empty:

DRIVER QUALIFICATION PACKET

APPLICATION FOR QUALIFICATION

Instructions:

SECTION A - APPLICANT INFORMATION

Residence history for the past three (3) years, beginning with your current address.

SECTION B – EMPLOYMENT HISTORY

SECTION C – DRIVING HISTORY/EXPERIENCE

To Be Read and Signed by Applicant

DRIVER APPLICANT DRUG AND ALCOHOL PRE-EMPLOYMENT STATEMENT

CONTROLLED SUBSTANCE & ALCOHOL TESTING INFORMATION ACKNOWLEDGEMENT/CONSENT FORM

Driver’s Safety Performance History & Information from DOT Regulated Previous Employer(s)

SECTION I – DRUG & ALCOHOL INFORMATION

MANDATORY USE FOR ALL ACCOUNT HOLDERS

IMPORTANT NOTICE

REGARDING BACKGROUND REPORTS FROM THE PSP Online Service

FOURTEEN-DAY PRIOR LOG FORM

VIOLATION AND ANNUAL REVIEW RECORD

ANNUAL REVIEW AND EVALUATION OF DRIVER’S RECORD