RPD LIMOUSINE Drivers Qualification Application

RPD LIMOUSINE CORP

Drivers Qualifications File Application
USDOT# 4260641
MC# 01652988

32 HARVESTVIEW DR
MONROE TOWNSHIP NJ 08831
NOTIFICATION OF RIGHTS

Pursuant to 49CFR part 391.23 (j), you have the following rights regarding investigated information 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. 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. If you wish to review previous employer provided investigative information you must submit a written request to the prospective employer, which may be done at any time, including when applying or as late as 30 days after being 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 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. If the driver has not arranged to pick up or receive the requested records within thirty 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 to the prospective employer. 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 a driver's request to correct the data that it does not agree to. If the previous employer corrects and forwards the data as requested, that employer must also retain the corrected information as part of the driver's safety performance history record and provide it to subsequent prospective employers when requests for this information are received. If the previous employer corrects the data and forwards it to the prospective motor carrier employer, there is no need to notify the driver. Drivers wishing to rebut information in records must send the rebuttal to the previous employer with instructions to include rebuttal in that driver's safety performance history.
Signature*

Clear
Date*

MonthDayYear
Date

Drivers Information
Full Name*

First NameMiddle InitialLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Best Contact Phone Number
Email*
example@example.com
Are you legally authorized to work in the U.S.?*

YesNo
Are you 25 Years Old?*

YesNo
Driver's License Information
State*
License No:*
Type or Class:*
Expiration Date:*
Endorsement:*
Have you ever been denied a license, permit or privilege to operate a motor vehicle?*

YesNo
If No Please Explain Here
Have you ever been denied a license, permit or privilege to operate a motor vehicle?
Has any license, permit or privilege ever been suspended or revoked?*

YesNo
If No Please Explain Here
Has any license, permit or privilege ever been suspended or revoked?

EMPLOYMENT RECORD

(MUST GO BACK THREE YEARS) Must list the complete mailing address: street number and name, city, state and zip code.
Last Employer*
Last Employer Business Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Business Phone*
Please enter a valid phone number.
Position Held*
Dates You Held Position:*
Salary? *
Reason For Leaving:*
ANY GAPS IN EMPLOYMENT AND/OR UNEMPLOYMENT MUST BE EXPLAINED. INCLUDEDATES (MONTH/YEAR) AND REASON.
Were you subject to the Federal Motor Carrier Safety Regulations (FMCSRs) while employed by this previous employer?*

YesNo
Was the previous job position designated as a safety sensitive function in any DOT regulated mode, subject to alcohol and controlled substances testing requirements as required by 49 CFR Part 40?*

YesNo
Second To Last Employer
Second To Last Employer Business Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Business Phone
Please enter a valid phone number.
Position Held
Dates You Held Position:
Salary
Reason For Leaving:
ANY GAPS IN EMPLOYMENT AND/OR UNEMPLOYMENT MUST BE EXPLAINED. INCLUDEDATES (MONTH/YEAR) AND REASON.
TO BE READ AND SIGNED BY APPLICANT

I authorize you to make investigations and inquiries into 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 interview(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 the 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 current/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) andI cannot agree on the accuracy of the information.”
Date*

MonthDayYear
Date
Signature*

Clear
This certifies that I completed this application, and that all entries on it and information in it are true and complete to the best of my knowledge. Note: A motor carrier may require an applicant to provide information in addition to the information required by the Federal Motor Carrier Safety Regulations.

Driving Policy Agreement and MVR Release Form

Purpose: No applicant will be hired into a position that requires driving as a key aspect of the position, nor will any existing employee be allowed to drive a personal car on Company business or a Company owned leased or rented vehicle, unless the requirements set forth in this procedure have been met.

Scope: This procedure pertains to any applicant for positions requiring driving, as well as all existing employees who drive a Company owned, leased or rented vehicle or a personal vehicle on Company business. Satisfactory driving performance and behavior is essential for the safety of our employees and the public.

Basic Requirements to Drive: Applicants and employees must have a valid driver’s license. A hardship or restricted license, or learner’s permit are not a valid license per this policy.
Employment with RPD Limousine Corp’s contingent upon having an acceptable Motor Vehicle Record (MVR).

Applicants must authorize RPD Limousine Corp to run an MVR Applicants may be disqualified for employment or driving positions if:

1. The MVR indicates that the applicant’s driver’s license is currently suspended, revoked, or canceled, including for administrative reasons (non-safety related).

2. Drivers indicate at risk driving behaviors by evidence of MVR records, call in complaints, direct observation by company employees, preventable collisions or any other valid source.

MVR Release and Policy Agreement:

In connection with any application made by me, I understand that investigative background inquiries may be made on me regarding motor vehicle information. I understand that you may be requesting information from various government agencies which maintain records concerning past driving records.
I, Print Applicants Name authorize without reservation, any party or agency contacted to furnish the above mentioned information and release all parties involved from any liability for doing so. I hereby consent to my employer, RPD Limousine Corp, obtaining such information. I recognize that these inquiries may be made randomly in the future and no further authorization is required by me. I understand the importance of driving defensively safely and that if the company determines my driving record indicates evidence of at risk driving, as described above, my employment can be terminated.
Applicant's Signature*

Clear
Date*

MonthDayYear
Date
Driver's License Number / State*

ACKNOWLEDGEMENT OF RECEIPT

DOT CONTROLLED SUBSTANCE AND ALCOHOL TESTING POLICY

PURSUANT TO FEDERAL REGULATIONS, THIS DOCUMENT MUST BE SIGNED AND WITNESSED BY COMPANY MANAGEMENT PERSONNEL PRIOR TO EMPLOYEE PERFORMING ANY DOT COVERED DUTIES.
I, Print Name hereby acknowledge that I have received the above summary of the DOT Drug and Alcohol Testing Policy as laid out in section 382 of the FMCSA regulations.
Signature (Company Representative)*

Clear
Date*

MonthDayYear
Date
Social Security Number*

Driver Certification of Violations
MOTOR CARRIER INSTRUCTIONS: Each motor carrier shall, at least once every 12 months, require each driver it employs to prepare and furnish it with a list of all violations of motor vehicle traffic laws and ordinances (other than violations involving only parking) of which the driver has been convicted, or on account of which he has forfeited bond or collateral during the preceding 12 months. (Section 391.27)

DRIVER REQUIREMENTS: Each driver shall furnish the list as required by the motor carrier above. If the driver has not been convicted of, or forfeited bond or collateral on account of any violation which must be listed, he shall so certify . (Section 391.27)
If no violations have occurred in the last 12 months write none. *
Type of Violation
Date

MonthDayYear
Date
Locations
Vehicle:
Date

MonthDayYear
Date
Locations
Vehicle:
I certify this document to be an accurate record of all traffic citations the past 12 months. *
Driver's Name
Drivers License No.*
State*
Expiration Date*
Driver's Signature*

Clear
Company Name & Address*
Reviewed By Title Keep This Record for 3 years

Alcohol and Controlled Substance Release
Employee Name*

First NameLast Name
Social Security Number (SSN):*
We are required by 49 CFR Part 382 to perform alcohol and controlled substances testing on all persons who operate a commercial motor vehicle and hold a commercial driver's license in the United States, Canada or Mexico.

You are required to submit to alcohol and controlled substances testing in accordance with the provisions in 49CFR Part 382. You are about to submit samples for alcohol and/or controlled substance testing. Your test is being given for the following reason(s).
- Pre-Employment: You are required to pass a pre-employment controlled substance test prior to performing any safety sensitive function for this company. Employment may be contingent upon satisfactory results.
- Post-Accident: You are required to take an alcohol and controlled substances test following any accidents that meet the requirement for post-accident drug and alcohol testing.
- Return-to-Duty: Prior to returning to duty, you must undergo an alcohol or controlled substances abuse test with negative results.
- Random: We are required to do random alcohol and controlled substances testing in accordance with minimum testing rates found in 49 CFR Part 382.305.
- Reasonable Suspicion: We can conduct alcohol and controlled substances testing on an employee when we have reasonable suspicion that he/she is violating the provisions for use of these substances. Reasonable suspicion is based on behaviors, appearance, speech, body movement or body odors.
  
  ● Unannounced after Return-to-Duty: You will be subject to unannounced alcohol and controlled substances testing following any return to duty and will consist of at least six tests within the first 12 months.
Employees who refuse to submit to alcohol and controlled substances testing will not be permitted to perform or continue to perform safety sensitive functions. Refusal to submit means: failure to provide adequate breath for the breath test, failure to provide adequate urine for a
controlled substances test after notice of testing has been given, or engaging in conduct which obstructs the testing process.

I understand that I am about to submit to an alcohol and/or controlled substances test. I agree to be tested and understand that a positive test will terminate my ability to perform any safety sensitive job functions in accordance with 49 CFR Part 40 and 382. My records will be kept confidential.
Your Name: *
Employee Signature*

Clear
Date*

MonthDayYear
Date

SELF CERTIFICATION OF SUBSTANCE ABUSE TESTING
Name*

First NameLast Name
Social Security Number (SSN):*
Have you tested positive, or refused to test, on any pre-employment drug test,or refused totest, on any pre-employment alcohol test during the past two years? Select one :*

YesNo
If yes, can you provide proof that you successfully completed all steps in theDOT return-to-duty requirements? Select one :*

YesNoN/A
I certify this information to be true and correct. *

Clear
Driver's Signature
Date*

MonthDayYear
Date
Should be Empty:

RPD LIMOUSINE CORP

Drivers Information

Driver's License Information

EMPLOYMENT RECORD

TO BE READ AND SIGNED BY APPLICANT

Driving Policy Agreement and MVR Release Form

ACKNOWLEDGEMENT OF RECEIPT

Driver Certification of Violations

Alcohol and Controlled Substance Release

SELF CERTIFICATION OF SUBSTANCE ABUSE TESTING