Driver Application

The Civil Rights Act of 1964 prohibits discrimination in employment practice because of race, color, religion, sex, or national origin. PI 90-202 prohibits discrimination.

PLEASE FILL OUT CLEARLY AND COMPLETE ALL SECTIONS THAT APPLY

In Case of an Emergency, Notify:

During the past two (2) years have you ever tested positive or refused to test on any pre- employment alcohol or drug test administered by an employer to which you applied but were not hired? 

Do you qualify for Interstate driving according to rules established by the DOT?

Do you have the required license certifications to perform this job?

Do you Illegally use drugs? (circle one) Yes No

Can you meet the attendance requirements of this job? (circle one) Yes No

Have you ever been convicted of a felony? (circle one) Yes No

 

References (someone who can verify employment dates other than a former employer or relative)

References (someone who can verify employment dates other than a former employer or relative)

References (someone who can verify employment dates other than a former employer or relative)

EMPLOYMENT RECORD FOR PAST 10 YEARS

Begin with your present or most recent job and work backwards in order, listing your employers for at least 10 years, including all fulltime and part-time employment. All time must be accounted for including military service, self-employment, and periods of unemployment.

May we call your employment? Yes/No

May we call your employment? YesNo

May we call your employment? YesNo

May we call your employment? YesNo

Driving Experience

 

List all involvement with truck and car including property damage for past five years- preventable and non.

Traffic Convictions and forfeitures for the past 5 years (if none write none)

Applicant written notification of: Safety Performance History Record Request:

(40.25) (391.23) Each motor carrier must investigate each driver's safety performance history with each of the driver's DOT-regulated employers during the preceding three years. A written record must be kept with respect to each previous employer contacted, or good faith efforts to do so, and must include the previous employer's name and address, date of contact or the attempts made, and the information received about the driver. The record must be placed in the driver investigation history file within 30 days of the date the driver's employment begins. The record must be maintained pursuant to section 391.53. (Form # 850 FS-C3) Previous Employee Safety Performance History: (391.23) Each motor carrier must investigate each driver's safety performance history with each of the driver's DOT- - regulated employers during the preceding three years. The Previous Employee Safety Performance History form allows a driver's previous employer to document the driver's safety performance history upon termination of employment. The completed form can then be forwarded to the driver's prospective employer(s) upon request. The information must be forwarded within 30 days of the request. Previous employers must keep a record of each request and the response for one year, including the date, the party to who it was released, and a summary identifying what was provided. The information of this form must be kept on file until three years after termination (form #854-F)

The applicant is hereby notified that they have the right to review and correct previous employer information. The applicant has the right to have the prior employer correct any errors and for that previous employer to re-send the correction to the prospective employer. The employee has the

right to have a rebuttal statement attached to alleged, erroneous information provided by the previous employer if they cannot agree on the accuracy of the information. Drivers with a DOT regulated employment history within the past three years can request to review prior employer information with written notification to the employer or prospective employer during the application process or within 30 days of being employed or being denied employment. Sparhawk Trucking, Inc, will provide this information within 5 business days after receiving the request providing Sparhawk Trucking, Inc has received the information from the prior employers. If this occurs, Sparhawk Trucking, Inc, will have 5 business days to provide information to the employee after the information is received. The driver has 30 days to make arrangements to receive or pickup the information. The employee will waive this right to review the information if this is not done within the 30-day time frame.

AUTHORIZATION FOR THE RELEASE OF INFORMATION FROM PAST EMPLOYERS

Requesting Company: Sparhawk Trucking Inc

Phone: 715-818-6098 Fax: 715-423-0313

TO BE READ AND SIGNED BY APPLICANT:

According to law established by the Department of Transportation, Sparhawk Trucking is required to conduct a background check on each applicant. By signing this release, you are allowing Sparhawk Trucking to conduct the background check. It is understood that the information in this application will be used and that prior employers will be contacted for purposes of investigation as required by 391.23 of the Motor Carrier Safety Regulations. It is agreed and understood that Sparhawk Trucking Inc. or his agents may investigate the applicants background to ascertain any and all information of concern to applicants record, whether same is of record or not, and applicant releases employers and person named herein form all liability for any damages on account of his furnishing such information. It is agreed and understood that if hired, the employee may be on a probationary period during which time he may be discharged without recourse. It is further understood an investigative report may be made whereby information is obtained through personal interviews with third parties, such as family members, business associates, financial sources, friends, neighbors, others with whom you are acquainted. This inquiry includes information as to your character, general reputation, person characteristics, and mode of living, whichever may be applicable. You have the right to make a written request within a reasonable period of time for a complete and accurate disclosure

of additional information concerning the nature and scope of any investigative consumer reports requested by us. It is understood that the applicant, by presenting the application for employment represents that the statements given by the applicant to information requested in this application are true, correct, and complete, and that any false, misleading, or incomplete statement of the information requested in this application shall be sufficient grounds for discharge from employment.

RELEASE FOR DRUG AND ALCOHOL INFORMATION

In accordance with 49CFR 382.405(f) and 382.413 (b), you are hereby authorized and requested to furnish to Sparhawk Trucking Inc. any and all information in your possession concerning my participation in your drug and alcohol testing program under 49 CFR Part 382. I specifically authorize you to release information on any alcohol tests with a concentration result of .04 or greater, positive controlled substance test results and/or refusals to be tested, within two years preceding the date of this request. I further authorize and request you to release any information in you possession concerning my evaluation by a substance abuse profession, the identity of the substance abuse profession, my participation in any treatment or rehabilitation recommended by the substance abuse professional and the results of any return to duty drug or alcohol test within two years preceding this request. Aphotocopy of this release shall be as valid as the original. This authorization shall be valid one year from date of signing hereof.

In connection with your application for employment with Sparhawk Trucking Inc, Prospective Employer, it's employees, agents or contractors may obtain one or more reports 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 you rights under the Fair Credit Reporting Act before taking any final adverse action. If any final adverse action is taken against you base 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 FMSCA in a decision to not hire you or to make any other 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 and a summary of your rights under the Fair Credit Reporting Act. 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. You may challenge the accuracy fo the date by submitting a request to http://dataqs.fmcsa.dot.gov. If you challenge crash or inspection information reported by a State, FMCSA cannot change or correct this data. Your request will be forwarded by the DataQs system to the appropriate State for adjudication. Any crash or inspection in which you were involved will display on you PSP report. Since the PSP report does not report, or assign, or imply fault, it will include all Commercial Motor Vehicle crashes where you were a driver or co-driver and where those crashes were reported to FMCAS, regardless of fault. Similarly, all inspections, with or without violations, appear on the PSP report. State citations associated with Federal Motor Carrier Safety Regulations (FMCSR) violations that have been adjudicated by a court of law will also appear, and remain, on a PSP report. The Prospective Employer cannot obtain background reports from FMCSA without authorization.

If you agree that the Prospective Employer may obtain such background reports, please read the following and sign below: I authorize Sparhawk Trucking Inc ("Prospective Employer") 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 authorizing the release of safety performance information including crash date 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.

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 http://datags.fmcsa.dot.gov. If I challenge 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. I understand that any crash or inspection in which I was involved will display on my PSP report. Since the PSP report does not report, or assign, or imply fault, I acknowledge it will include all CMV crashes where I was a driver or co-driver and where those crashes were reported to FMCSA, regardless of fault. Similarly, I understand all inspections, with or without violations, will appear on my PSP report, and State citations associated with FMCSR violations that have been adjudicated by

acourt of law will also appear, and remain, on my PSP report.

I have read the above Disclosure Regarding Background Reports provided to me by Prospective Employers and I understand that if I sign this Disclosure and Authorization, 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.

NOTICE: This form is made available to monthly account holders by NIC on behalf of the U.S. Department of Transportation, Federal Motor Carrier Safety Administration (FMCSA Account holders are required by federal law to obtain an Applicant's written or electronic consent prior to accessing the Applicant's PSP report. Further, account holders are required by FMCSA to use the language contained in the Disclosure and Authorization form to obtain an Applicant's consent. The language must be used in whole, exactly as provided. Further, the language on this form must exist as one stand-alone document. The language may NOT be included with other consent forms or any other language. NOTICE: The prospective employment concept referenced in this form contemplates the definition of "employee" contained at 49 C.F.R. 383.5 Last Updated 11/12/2020

 

DOT Drug & Alcohol Policy Addendum
Effective Date: 1/6/2020
Any commercial motor vehicle driver for Sparhawk Trucking Inc.
(herein referred to as the “Company”) who is subject to the FMCSA’s drug and alcohol testing regulations in 49 CFR Part 382 must also comply with the CDL Driver Drug & Alcohol Clearinghouse regulations in Part 382, Subpart G. The Clearinghouse is an online database providing employers and enforcement agencies with information about drivers who have violated Federal Motor Carrier Safety
Administration (FMCSA) controlled substances (“drug”) or alcohol testing rules. The Company is prohibited from using a driver to perform safety-sensitive functions if at any time the Company obtains information from the Clearinghouse indicating that the driver has committed a testing violation and has not completed the return-to-duty process as outlined in the Company’s DOT Drug & Alcohol Policy.
Drivers will be notified by FMCSA when the Company obtains information from the Clearinghouse, or when information concerning the driver is added, revised, or removed.
Reporting: For any driver subject to the Clearinghouse rules, the following violations occurring, or milestones reached, on or after January 6, 2020, will be reported to the Clearinghouse by the Company, its service providers, its Medical Review Officer(s), and/or its Substance Abuse Professional(s) as
required by FMCSA regulation:
• Any verified positive, adulterated, or substituted DOT drug test
• Any confirmed DOT alcohol test result of 0.04 or higher
• Any refusal to submit to a DOT-required drug or alcohol test
• Any verified and documented “actual knowledge” that the driver violated the DOT drug or alcohol rules, including:
o Any on-duty alcohol use, including any citation for driving under the influence of alcohol (DUI/DWI) while driving a commercial motor vehicle
o Any alcohol use within 4 hours before going on duty
o Any alcohol use within 8 hours of an accident or before a post-accident test is complete (whichever occurs first)
o Any prohibited drug use while on duty
• Successful completion of the return-to-duty process following treatment*
• Any negative DOT return-to-duty test*
• Successful completion of follow-up testing*
*Only reported if the underlying violation occurred on or after January 6, 2020.
Each report to the Clearinghouse will include the driver’s name, date of birth, commercial driver’s license number, and state of issuance, in addition to violation and/or testing information.
Queries: The Company will purchase reports (“queries”) from the Clearinghouse at the following times:
• Annually for all drivers, and
• Prior to employment of any new drivers.
Granting of Consent: Drivers must grant consent for the Company to purchase Clearinghouse reports as follows:
• Drivers must create a Clearinghouse account and log in to grant the Company consent to obtain a “full” report prior to employment with the Company.
• Drivers must sign a separate “Consent for Limited Queries” form granting the Company access to “limited” queries obtained annually. Drivers have the right to limit the length of time for which such consent is valid but making it valid for the length of employment with the Company is recommended.
• If a limited query reveals that the Clearinghouse contains information about a driver, the Company will inform the driver that he or she must immediately log in to the Clearinghouse to grant consent for the Company to obtain the driver’s full Clearinghouse record. Such record will be obtained within 24 hours of the limited query. Drivers who refuse to grant the consent described above will be removed from all safety-sensitive functions as defined in §382.107. Safety-sensitive functions will not be allowed to resume until the driver has granted the required consent, the Company obtains the required Clearinghouse report, and the Clearinghouse report shows that the driver is eligible to perform safetysensitive functions.
Notice of Violations: Drivers must notify the Company in writing if they have violated the drug and/or alcohol prohibitions of 49 CFR Parts 40 or 382 under the testing program of any other employer. The notification must be received before the end of the business day following the day the driver received
notice of the violation, or prior to performing any safety-sensitive function, whichever comes first.
Driver Accounts: Drivers who do not yet have a Clearinghouse account are encouraged to create one online at clearinghouse.fmcsa.dot.gov, and are highly encouraged to provide an email address at which to be contacted. Drivers are permitted to see their own Clearinghouse records free of charge and may
challenge the accuracy of information reported to the Clearinghouse, but not the accuracy of test results or refusals, using the procedures contained in §382.717.
Use of Information: The Company will use a driver’s information from the Clearinghouse only to determine if the driver is prohibited from performing safety-sensitive functions. The Company will not divulge, nor permit any other person or entity to divulge, any driver-specific information from the Clearinghouse to any person or entity not directly involved in making such determination.

 

I acknowledge that I have received a copy of the Company’s Addendum to its DOT Drug & Alcohol Policy dated; January 6, 2020.