Prosafe Utility Contractors Employment Application

PROSAFE UTILITY CONTRACTORS LLC
Name
Date

MonthDayYear
Date
Address

Street Address

CityState

Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
Social Security Number
Position you are applying for
Available Start Date

MonthDayYear
Date
Desired Pay
Employment Desired

Full TimePart TimeTemporary
If Selected for employment, are you willing to provide a background check?

YesNo
Are you a current trade union member?

NOYes- Please list
Driving - No person who operates a commercial motor vehicle shall at any time have more than 1 drivers license (49 CFR383.21 I certify that I do not have more than 1 motor vehicle license, the information for which is listed below. Include all licenses held in the last 3 years; attach additional sheets if applicable. Prosafe requires each driver to prepare a list of Violations of motor vehicle traffic laws and ordinances (other than parking) of which the driver has been convicted or of which he/she has forfeited bond or collateral during the preceding 12 months. Drivers who have pro
Do you have a current CDL?

YesNo
If Yes- Select 1

ABC
Fed Med Card Exp
Select any Special Endorsements

TPHNSX
Select any Restrictions

BEFGKLMNOVXZ
Do you Hold a current Drivers License?

YesNo-Please list why.
Have you ever been denied a License, permit, or privilege to operate a motor vehicle?

YesNO
Has any license, permit, or privledge ever been suspended or revoked?

NoYes, Please state why.
List any other driving experience *
Excavators, Bulldozers, Loaders (e.g., Front-End Loader), Backhoes, Motor Graders, Cranes, Forklifts, Vac Trucks, and Boom Lifts OR NA.
Please list Drivers License #
Accident record for the past 3 years.
Date

MonthDayYear
Date
Nature of Accident
No of Fatalities
No of Injuries
Chemical Spills YES or NO
Date

MonthDayYear
Date
Nature of Accident
No of Fatalities
No of Injuries
Chemical Spills- YES or NO
Date

MonthDayYear
Date
Nature of Accident
No of Fatalities
No of Injuries
Chemical Spills- YES or NO
Traffic Convictions and forfeitures for the past 3 years (other than parking violations
Date

MonthDayYear
Date
Violation or Offense
State of Violation
Penalty (Forfeited bond, collateral and/or points)
Date

MonthDayYear
Date
Violation/Offense
State of Violation
Penalty (Forfeited bond, collateral and/or points)
Date

MonthDayYear
Date
Violation/Offense
State of Violation
Penalty (Forfeited bond, collateral and/or points)
Previous 3 Year Residency
Current Address & Duration

Street Address

Street Address Line 2

CityState

Zip Code
No. of years
Previous Address- Only fill out if you have not lived at your current residence for longer than 3 years.

Street Address

Street Address Line 2

CityState

Zip Code
No. of years
Previous Address

Street Address

Street Address Line 2

CityState

Zip Code
No. of Years
Current (most recent) Employer
I give you permission to contact this employer

YES
Address
Phone
Position Held
Salary
From
To
Reason for leaving
Explain any GAPS in employment Include Mo/Yr reason
While employed here, were you subject to the Federal Motor Carrier Safety Regulations.

YesNo
Was the job designated as a safety-sensitive function in any department of transportation- regulated mode subject to alochol and controlled substances testing as required by 49 CFR, Part 40

YESNO
2nd Most Recent Employer- Name
Permission to contact this employer

Yes
Phone
Address
Position Held
Salary
From
To
Reason for leaving
Explain any GAPS in employment Include Mo/Yr reason
While employed here, were you subject to the Federal Motor Carrier Safety Regulations?

YesNo
Was the job designated as a safety-sensitive function in any Department of Transportation- regulated mode subject to Alcohol and controlled substances testing as required by 49 CFR, part 40?

YesNo
Name
Permission to contact this employer

Yes
Phone
Address
Position Held
Salary
From
To
Reason for leaving
Explain any GAPS in employment Include Mo/Yr reason
While employed here, were you subject to the Federal Motor Carrier Safety Regulations?

YesNo
Was the job designated as a safety-sensitive function in any Department of Transportation- regulated mode subject to Alcohol and controlled substances testing as required by 49 CFR, part 40?

YesNo
Background Checks
I have read and understand the FCRA Candidate Disclosure for the Procurement of Consumer Reports form and, if applicable, the California Candidate Disclosure for the Procurement of Investigative Consumer Reports form. I have also read and understand the attached Summary of Rights under the Fair Credit Reporting Act and State Law Disclosures.13340_fcra.pdf

I understand that if employed, providing false or misleading information on my application or during interviews may lead to my termination. I also agree to follow all company rules and regulations.

I understand that the information I provide about my current and previous employment may be used, and those employers will be contacted to investigate my safety performance history as required by 49 CFR 391.23. I have the right to:
- Review information from current or previous employers.
- Have previous employers correct errors in the information and resend the corrected information to the prospective employer.
- Attach a rebuttal statement to any disputed information if I cannot agree with previous employers on its
I certify that this application is complete and all information is true and accurate to the best of my knowledge.

Note: A motor carrier may request more information than Federal Motor Carrier Safety Regulations require.
Regarding Job Partners
By signing below,

I authorize Prosafe Utility Contractors ("the Company") to share the contents of thisconsumer report or investigative consumer report with its partners and clients to facilitate my placement into anemployment, independent contractor, or volunteer relationship with them. The Company will only share thebackground report as necessary and authorized to assign me to a client, partner company, or organization. Ifthe Company hires or engages me, this consent will remain valid, and the Company may obtain reportsthroughout my employment, contract, or tenure where allowed by state law. I also understand that information inmy job application or disclosed by me before or during my employment, contract, or tenure, if any, may be used to obtain consumer reports and/or investigative consumer reports.

By signing below, I authorize law enforcement agencies, educational institutions (public and private),information service bureaus, credit bureaus, record/data repositories, courts (federal, state, and local), motor vehicle records agencies, my past or present employers, the military, and other individuals and sources to provide any and all information about me requested by the consumer reporting agency.

If the applicant is under 18 years old, a Legal Guardian must provide their email address and signature below.

I authorize GoodHire and its agents to contact my current employer, if necessary, to verify my current employment status after the following date:
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Covered Employee certificate of Receipt of the Controlled Substances and Alcohol use, testing policy for Prosafe Utility Contractors (the employer)
CERTIFICATE OF RECEIPT

Pursuant to Federal Regulation 49 CFR §382.601(d)

In accordance with Federal Regulation 49 CFR §382.601(d) each covered driver is required to sign astatement certifying receipt of the materials described in §382.601 of this policy.

STATEMENT OF POLICY

It is the policy of the Company that all covered drivers and employees shall refrain from the use ofany prohibited controlled substances at all times, whether on duty or off duty. Furthermore, allcovered drivers and employees shall refrain from the use of alcohol within four (4) hours prior to theperformance of, and during the performance of, any safety-sensitive function, including the operationof a commercial motor vehicle requiring a Commercial Driver’s License (CDL) on a public roadway.These requirements apply to both mandated (DOT-regulated) and non-mandated (non-DOT)employees.

All covered drivers are subject to testing for the following substances:
- Marijuana (THC)
- Cocaine
- Opiates
- Amphetamines
- Phencyclidine (PCP)
- Synthetic opioids
- Alcohol
All driver applicants shall be required to undergo a pre-employment drug test. A verified negative test result must be received by the employer prior to the applicant’s performance of anysafety-sensitive function.

CONSEQUENCES OF PROHIBITED CONDUCT

Any driver or employee who:
- Produces a positive controlled substances test result,
- Produces an alcohol test result of 0.02 or greater, or
- Engages in any other conduct prohibited under Section B of this policy, shall be immediately removed from the performance of safety-sensitive functions. Such individuals shall be subject to disciplinary action up to and including termination of employment.
- A driver applicant who produces a positive test result shall not be hired.
TESTING PROGRAM ADMINISTRATOR

The employer has contracted with Absolute Mobile Testing, LLC (AMT) as the designated alcohol and controlled substances testing program administrator, as authorized under applicable Federal regulations. AMT shall administer the testing program on behalf of the Company.

ADDITIONAL REQUIREMENTS

Pursuant to Federal regulations, the employer reserves the right to implement and enforce requirements that are more stringent than those mandated by regulation. Such requirements may include additional provisions relating to the safe operation of commercial motor vehicles, as well as employee health and safety, including controlled substances and alcohol testing.

By signing below, the undersigned acknowledges, understands, and agrees to comply with all provisions of the Company's Controlled Substances and Alcohol Use and Testing Policy.

ACKNOWLEDGEMENT OF RECEIPT

I hereby acknowledge receipt of the U.S. Department of Transportation (DOT), Federal MotorCarrier Safety Administration (FMCSA) Controlled Substances and Alcohol Use and TestingPolicy Statement. I agree to review the contents of this policy, familiarize myself with itsrequirements, and comply fully with its provisions.
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PROSAFE UTILITY CONTRACTORS LLC

Accident record for the past 3 years.

Traffic Convictions and forfeitures for the past 3 years (other than parking violations

Previous 3 Year Residency

Background Checks

Regarding Job Partners

Covered Employee certificate of Receipt of the Controlled Substances and Alcohol use, testing policy for Prosafe Utility Contractors (the employer)