DRIVER'S APPLICATION FOR EMPLOYMENT

DRIVER'S APPLICATION FOR EMPLOYMENT
Applicant Name (print)
Date of Application

MonthDayYear
Date
Company
TADD LLC
In compliance with Federal and State equal employment opportunity laws, qualified applicants are considered for all positions without regard to race, color, religion, sex, national origin, age, marital status, veteran status, non-job related disability, or any other protected group status.
TO BE READ AND SIGNED BY APPLICANT
I authorize you to make such investigations and inquiries of my personal, employment, financial or medical history and other related matters as may be necessary in arriving at an employment decision. (Generally, inquiries regarding medical history will be made only if and after a conditional offer of employment has been extended I hereby release employers, schools, health care providers and other persons from all liability in responding to inquiries and releasing information in connection with my application. In the event of employment, I understand that false or misleading information given in my application or inter- view(s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the Company. I understand that information I provide regarding current and/or previous employers may be used, and those employer(s) will be contacted, for the purpose of investigating my safety performance history as required by 49 CFR 391.23(d) and (e I understand that I have the right to: Review information provided by previous employers; Have errors in the information corrected by previous employers and for those previous employers to re-send the corrected information to the prospective employer; and Have a rebuttal statement attached to the alleged erroneous information, if the previous employer(s) and I cannot agree on the accuracy of the information.
Signature

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Date

MonthDayYear
Date
DATE EMPLOYED

MonthDayYear
Date
POINT EMPLOYED
DEPARTMENT (IF REJECTED, SUMMARY REPORT OF REASONS SHOULD BE PLACED IN FILE)
CLASSIFICATION
SIGNATURE OF INTERVIEWING OFFICER

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APPLICANT TO COMPLETE
(answer all questions)
Position(s) Applied for
Last Name
First Name
Middle Name
Social Security No.
List your addresses of residency for the past 3 years.
Street
City
State
Zip Code
Phone
yr./mo.
Street
State & Zip Code
yr./mo.
Street
State & Zip Code
yr./mo.
Street
City
State & Zip Code
yr./mo.
Do you have the legal right to work in the United States?
Date of Birth (Required for Commercial Drivers)
Date of Birth

MonthDayYear
Date
Can you provide proof of age?
Have you worked for this company before?
From
To
Rate of Pay
Position
Reason for leaving
Are you now employed?
If not, how long since leaving last employment?
Who referred you?
Rate of pay expected
Have you ever been bonded?
Name of bonding company
Have you ever been convicted of a felony?
If yes, please explain fully on a separate sheet of paper. Conviction of a crime is not an automatic bar to employment-all circumstances will be considered.
Is there any reason you might be unable to perform the functions of the job for which you have applied [as described in the attached job description]?
If yes, explain if you wish.
EMPLOYMENT 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 addi- tional 7 years' information on those employers for whom the applicant operated such vehicle. (NOTE: List employers in reverse order starting with the most recent. Add another sheet as necessary
EMPLOYER
Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Contact Person
Phone Number
Please enter a valid phone number.
DATE
FROM
TO
POSITION HELD
STATE
SALARY/WAGE
CONTACT PERSON

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 NOWERE YOU SUBJECT TO THE FMCSRs¹ WHILE EMPLOYED?
REASON FOR LEAVING
WERE YOU SUBJECT TO THE FMCSRs¹ WHILE EMPLOYED?

YESNO
EMPLOYMENT HISTORY (continued)
EMPLOYER
NAME
Type a question
DATE
FROM
TO
POSITION HELD
CITY
ZIP

YESNOPHONE NUMBER
STATE
SALARY/WAGE
CONTACT PERSON
REASON FOR LEAVING
REASON FOR LEAVING
YESNO

WAS YOUR JOB DESIGNATED AS A SAFETY-SENSITIVE FUNCTION IN ANY DOT-REGULATED MODE SUBJECT TO THE DRUG ANDALCOHOL YESNO TESTING REQUIREMENTS OF 49 CFR PART 40?WERE YOU SUBJECT TO THE FMCSRs¹ WHILE EMPLOYED?
EMPLOYER
Name
DATE
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
FROM
TO
POSITION HELD
DATE
NAME
FROM
TO
POSITION HELD
CONTACT PERSON
REASON FOR LEAVING
ACCIDENT RECORD FOR PAST 3 YEARS OR MORE (ATTACH SHEET IF MORE SPACE IS NEEDED) IF NONE, WRITE NONE
DATES
NATURE OF ACCIDENT HEAD-ON, REAR-END, UPSET, ETC
FATALITIES
INJURIES
HAZARDOUS MATERIAL SPILL
TRAFFIC CONVICTIONS AND FORFEITURES FOR THE PAST 3 YEARS (OTHER THAN PARKING VIOLATIONS) IF NONE, WRITE NONE
List all driver licenses or permits held in the past 3 years
Have you ever been denied a license, permit or privilege to operate a motor vehicle?

YESNO
Has any license, permit or privilege ever been suspended or revoked?

YESNO
Has any license, permit or privilege ever been suspended or revoked?
IF THE ANSWER IS YES, GIVE DETAILS
DRIVING EXPERIENCE

TRACTOR AND SEMI TRAILERTRACTOR - 2 TRAILERSTRACTOR AND SEMI-TRAILERYES NOTRACTOR - TWO TRAILERSYES NOMore than 8 passengers More than 15 passengersYES NOMOTORCOACH - SCHOOL BUSYES NOMOTORCOACH - SCHOOL BUS
OTHER
LIST STATES OPERATED IN FOR LAST FIVE YEARS
SHOW SPECIAL COURSES OR TRAINING THAT WILL HELP YOU AS A DRIVER
WHICH SAFE DRIVING AWARDS DO YOU HOLD AND FROM WHOM?
EXPERIENCE AND QUALIFICATIONS - OTHER SHOW ANY TRUCKING, TRANSPORTATION OR OTHER EXPERIENCE THAT MAY HELP IN YOUR WORK FOR THIS COMPANY
SHOW ANY TRUCKING, TRANSPORTATION OR OTHER EXPERIENCE THAT MAY HELP IN YOUR WORK FOR THIS COMPANY
LIST COURSES AND TRAINING OTHER THAN SHOWN ELSEWHERE IN THIS APPLICATION
LIST SPECIAL EQUIPMENT OR TECHNICAL MATERIALS YOU CAN WORK WITH (OTHER THAN THOSE ALREADY SHOWN)
EDUCATION
HIGHEST GRADE COMPLETED
HIGH SCHOOL
COLLEGE
LAST SCHOOL ATTENDED
TO BE READ AND SIGNED BY APPLICANT
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.

Signature: PAGE 4 15F (Rev. 2/05) 691
Signature

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Date

MonthDayYear
Date
PRE-EMPLOYMENT DRUG TESTING POLICY
Pre-Employment Drug Testing Policy
Pursuant to regulations promulgated by the Department of Transportation, the Company has implemented a drug testing policy that includes pre-employment testing for drugs. Before you will be qualified as a driver, you must first pass a pre-employment drug test and a physical examination. In addition, you will also be required to give the Company written authorization to obtain the results of all your D. O. T. required drug and alcohol test for the past two years, and the results of those tests (including any refusals to be tested Should you fail or refuse to take the drug test, and/or physical examination as directed, or should you fail to comply with the required testing procedures (including but not limited to adulterating, altering, or other tampering with your specimen) or should you in some other way obstruct the testing or examination process, you will not be qualified as a driver with this Company.

If the MRO reports to the Company a positive drug test, you will not be qualified as a driver with this Company.

I hereby acknowledge receipt of the Company's Pre-employment Drug Policy.
[Date]

MonthDayYear
Date
[Applicant's Signature]

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PRE-EMPLOYMENT EMPLOYEE ALCOHOL AND DRUG TEST STATEMENT
Sec.40.25(j) As the employer, you must 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(b5) and (e

W225 S9135 Mt Carmel Rd Big Bend, WI 53103
Prospective Employee Name: (print)
The prospective employee is required by Sec. 40.25(j) and TADD LLC to Respond to the following questions:

1) Have you EVER tested positive, or refused to test, on any drug or alcohol test administered by ANY employer, Pre-Employment or otherwise?
Check one

YesNo
2 If you answered yes, can you provide/obtain proof that you've successfully completed the DOT return-to-duty requirement?

YesNo
Prospective Employee Signature

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Date

MonthDayYear
Date
Witnessed By: (signature)

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Date

MonthDayYear
Date
DISCLOSURE AND RELEASE
In connection with my application for employment (including contract for services) with B&T Mail Service, Inc., I understand that consumer reports which may contain public record information may be requested from DAC Services, Tulsa, Oklahoma. These reports may include the following types of information: names and dates of previous employers, reason for termination of employment, work experience, accidents, etc. I further understand that such reports may contain public record information concerning my driving record, workers' compensation claims, credit, bankruptcy proceedings, criminal records, etc., from federal, state and other agencies which maintain such records; as well as information from DAC concerning previous driving record requests made by others from such state agencies, and state provided driving records.

I AUTHORIZE, WITHOUT RESERVATION, ANY PARTY OR AGENCY CONTACTED BY DAC TO FURNISH THE ABOVE-MENTIONED

I have the right to make a request to DAC, upon proper identification, to request the nature and substance of all information in its files on me at the time of my request, including the sourced of information; and the recipients of any reports on me which DAC gas previously furnished within the two year period preceding my request. I hereby consent to your obtaining the above information from DAC, and I agree that such information which DAC gas or obtains, and my employment history with B&T Mail Service, Inc. if I am hired, will be supplied by DAC to other companies which subscribe to DAC Services.

I hereby authorize procurement of consumer report(s If hired (or contracted), this authorization shall remain on file and shall serve as ongoing authorization for you to procure consumer reports at any time during my employment (or contract) period.
Print Name
Social Security #
Applicant's Signature

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Date

MonthDayYear
Date
Driver's License #
SAFETY PERFORMANCE HISTORY INVESTIGATION
I hereby authorize release of information from my Department of Transportation regulated drug and alcohol testing records by my previous employer, listed below, to the POTENTIAL EMPLOYER. This release is in accordance with DOT Regulation 49 CFR Part 40, Section 40.25. I understand that information to be released by my previous employer, is limited to the following DOT-regulated testing items: 1. Alcohol tests with a result of 0.04 or higher; 2. Verified positive drug tests; 3. Refusais to be tested; 4. Other agency drug and alcohal testing regulations; 5. Information obtained from previous employers of a drug and alcohol rule violation; 6. Documentation, if any, of completion of the return-to-duty pracess following a rule violation. I further authorize my former employer to rélease my safety performance history information to my prospective employer for investigation purposes as required by FMCSR 391.23, 382.405 (f) & 382.413(b) for the 3 years preceding this release. You are released from any and all liability that may result from furnishing such information. A photocopy of this release shall be as valid as the original.
Printed Name
Past Employer
Contact Name
Phone#
Signature

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Should be Empty:

DRIVER'S APPLICATION FOR EMPLOYMENT

TADD LLC

TO BE READ AND SIGNED BY APPLICANT

DEPARTMENT (IF REJECTED, SUMMARY REPORT OF REASONS SHOULD BE PLACED IN FILE)

APPLICANT TO COMPLETE

EMPLOYMENT HISTORY

EMPLOYER

DATE

EMPLOYER

DATE

EMPLOYER

DATE

DATE

ACCIDENT RECORD FOR PAST 3 YEARS OR MORE (ATTACH SHEET IF MORE SPACE IS NEEDED) IF NONE, WRITE NONE

DATES

NATURE OF ACCIDENT HEAD-ON, REAR-END, UPSET, ETC

FATALITIES

INJURIES

HAZARDOUS MATERIAL SPILL

TRAFFIC CONVICTIONS AND FORFEITURES FOR THE PAST 3 YEARS (OTHER THAN PARKING VIOLATIONS) IF NONE, WRITE NONE

EXPERIENCE AND QUALIFICATIONS - OTHER SHOW ANY TRUCKING, TRANSPORTATION OR OTHER EXPERIENCE THAT MAY HELP IN YOUR WORK FOR THIS COMPANY

TO BE READ AND SIGNED BY APPLICANT

PRE-EMPLOYMENT DRUG TESTING POLICY

PRE-EMPLOYMENT EMPLOYEE ALCOHOL AND DRUG TEST STATEMENT

DISCLOSURE AND RELEASE

SAFETY PERFORMANCE HISTORY INVESTIGATION