The purpose of this application is to determine whether or not the applicant is qualified to operate motor carrier equipment according to the requirments of the Federal Motor Carrier Safety Regulations and the Company named above.
INSTRUCTIONS TO APPLICANT: Please answer all questions.
*The Age Discrimination of Employment Act of 1967 prohibits discrimination on the basis of age with respect to individuals who are at least 40 but less than 70 years of age.
From: date* To: date* .
from: date To: date*
EDUCATION AND EMPLOYMENT HISTORY
Please indicate the highest grade completed (If none please write "NONE"):
Give a Complete Record of all employment for the past TEN years. Including all self-employment, all commercial driving experience, and unemployment. Begin with the most recent job.
Dates employed. From: date . To: date .
Dates employed. From: date . To: blank .
Accident Record for the past three years
Traffic Convictions and Forfeitures for the last three years (All convictions, other than parking violations)
List each drivers license held in the past 3 years
Name: Address: Phone:Years Known:
Name: Address: Phone:blankYears Known:
It is agreed and understood that any misrepresentation given on this application for qualification shall be considered an act of dishonesty.
I give the motor carrier and its agents or representatives the right to investigate all references and to secure additional information about my employment background. I hereby release from all liability for damages the motor carrier and its agents or representatives for seeking such information and all other persons, corporations or organizations for furnishing such information.
I agree to furnish such additional information and complete such examinations as may be required to complete my employment file.
It is agreed and understood that this application for qualification in no way obligates the motor carrier to employ me.
It is agreed and understood that if qualified to operate motor carrier equipment, I may be on a probationary period, during which I may be disqualified without recourse.
This certifies that this application was completed by me, and that all entries on it and information in it are true and complete to the best of my knowledge.
I hereby consent to submit to a drug or alcohol test and to furnish a sample of my urine, breath, and/or blood for analysis, as shall be determined by
ENGLUND EQUIPMENT COMPANY in order to meet with their policy
regarding the selection of applicants for employment.
I further authorize and give full permission to have the Company and/or its authorized agents and physicians to send the specimen or specimens so collected to a laboratory for a screening test for the presence of any prohibited substances under the policy, and for the laboratory or other testing facility to release any and all documentation relating to such test to the Company. I further agree to and hereby authorize the release of the results of said tests to the Company.
I understand that it is the current use of illegal drugs that would prohibit me from being employed at this Company.
I further agree to hold harmless the Company and its agents and physicians from any liability arising in whole or part, out of the collection of specimens, testing, and use of the information from said testing in connection
with the Company's consideration of my application of employment.
I further agree that a reproduced copy of this pre-employment consent and release form shall have the same force and effect as the original.
If you are hired, you will be subject to the law 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 Suspension -- 382.307
Return to Duty -- 382.309
Follow-up -- 382.311
A Driver who test positive to a controlled substance(s) 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 a motor carrier until and unless the Driver completes the Substance Abuse Professionals (SAP) evaluation, referral and education/treatment process as described in FMCSR Part 40, Subpart O.
I have carefully read the foregoing and fully understand its contents and testing requirements. I acknowledge that my signing of this consent and release form is a voluntary act on my part and that I have not been coerced into signing this document by anyone.
I hereby authorize you to release the following information to ENGLUND EQUIPMENT COMPANY for purposes of investigation as required by Sections 391.23 and 391.25 of the Federal Motor Carrier Safety Regulations. You are released from any and all liability which may result from furnishing such information.
In accordance with the provisions of Sections 604 and 607 of the Fair Credit Reporting Act, Public Law 91-508, as amended by the Consumer Credit Reporting Act of 1996 (Title 11, Subtitle D, Chapter 1, of Public Law 104-208), 1 hereby certify the following:
1. The consumer (applicant) has authorized in writing the procurement of this report; 2. The consumer (applicant) has been informed in a separate written disclosure that a consumer report may be obtained for employment purposes; 3. The information requested below will be used for a ''permissible purpose'' (i.e., information for employment purposes) and will be used for no other purpose; 4. The information being obtained will not be used in violation of any federal or state equal opportunity law or regulation; and 5. Before taking an adverse action based in whole or in part on the report the consumer (applicant) will receive a copy of the requested report and the summary of consumer rights as provided with the report by the consumer reporting agency.
I also hereby certify that this report request and the above applicant's release notice meet the definition of ''permissible uses'' of state motor vehicle records under the provisions of the Driver's Privacy Protection Act of 1994 (Public Law 103-322, Title XXX, Section 300002(a
The following Driver has made application with our company. In accordance with Section 391.23, Federal Department of Transportation Regulations, please furnish the undersigned with the applicant's driving record for the past 10 years.
COMPANY NAME / ADDRESS: ENGLUND EQUIPMENT COMPANY 11498 W. Buckeye Rd Cashion Az 85329
To release and forward the information requested by section 3 of this document concerning my Alcohol and Controlled Substances Testing records within the previous 3 years from: (employment application date)
To: Prospective Employer: ENGLUND EQUIPMENT COMPANY
Attention: Safety Department
Street: 11498 W. Buckeye Rd Cashion Az 85329
In compliance with §40.25(g) and 391.23(h), the release of this information must be made in a written form that ensures confidentiality, such as fax, email, or letter.
This information is being requested in compliance with §40.25(g) and 391.23