Application for Employment

Commercial Driver
Equal Opportunity Employer

–

Elite HR Logistics is an equal opportunity employer and does not discriminate against otherwise qualified applicants on the basis
or race, color, creed, religion, ancestry, age, gender, marital status, sexual orientation, national origin, disability or handicap, or veteran status. We comply with all Federal, State, and Local laws concerning discrimination in employment.

Position(s) Applied for:

Date of Application:

/

/

Name:

(Last)

(First)

(Middle)

Nickname or other names you have used while working:

Street Address:

Apt./Unit No.:

City:

State:

Zip Code:

Mailing Address:

Apt./Unit No.:

City:

State:

Zip Code:

Home Phone:

Cell Phone:

Cell Provider:

Email Address:

Emergency Contact:

(Name)

(Relationship)

(Contact Number)

Social Security #:

-

-

Date of Birth:

/

/

Have you ever been employed by Elite HR Logistics before?

Yes

No

If yes, please give dates and position:

Can you present evidence of your U.S. citizenship or proof of your legal right to live and work in this country?

Yes

No

Are you telephone accessible?

Yes

No

Are you willing to take a drug screen according to our policy?

Yes

No

Will you release your background information inclusive of criminal records?

Yes

No

What areas are you willing to work?

(Applicant Signature)

(Print Name)

(Date)

*No applicant will be denied employment solely on the grounds of conviction of a criminal offense. The nature of the offense, date of the offense, the surrounding circumstances, and the relevance of the offense to the

position(s) applied for may, however, be considered.
*The ability to be bonded is a condition of hire: A Photograph and a copy of your fingerprints may be required as part of or during your employment.

3838 Watt Ave. Suite D-404 | Sacramento, CA 95821

916-484-4300(p) | 916-484-7518(f)
www.elitehrlogistics.com 

PAGE 1 OF 16

NOTICE REGARDING BACKGROUND INVESTIGATION

Important – Please read carefully before signing acknowledgement

Employer Elite HR Logistics may obtain information about you from a consumer reporting agency for employment purposes. Thus, you may be the subject of a “consumer report” and/or an “investigative consumer report” which may include information about your character, general reputation, personal characteristics, and/or mode of living and which can involve personal interviews with sources such as your neighbors, friends, or associates. These reports may be obtained at any time after receipt of your authorization and, if you are hired, throughout your employment. You have the right, upon written request made within a reasonable time after receipt of this notice, to request disclosure of the nature and scope of any investigative consumer report. Please be advised that the nature and scope of the most common form of investigative consumer report obtained with regard to applicants for employment is an investigation into your education and/or employment history conducted CDTA Your national compliance solution,9275 Sky Park Court, Suite 105,San Siego,Ca.888.908.2382. or another outside organization. The scope of this notice and authorization is all-encompassing, however, allowing Employer to obtain from any outside organization all manner of consumer reports and investigative consumer reports now and, if you are hired, throughout the course of your employment to the extent permitted by law. As a result, you should carefully consider whether to exercise your right to request disclosure of the nature and scope of any investigative consumer report.

ACKNOWLEDGMENT AND AUTHORIZATION

I acknowledge receipt of the NOTICE REGARDING BACKGROUND INVESTIGATION and A SUMMARY OF YOUR RIGHTS UNDER THE FAIR CREDIT REPORTING ACT and certify that I have read and understand both of those documents. I hereby authorize the obtaining of “consumer reports” and/or “investigative consumer reports” at any time after receipt of this authorization and, if I am hired, throughout my employment. To this end, I hereby authorize, without reservation, any law enforcement agency, administrator, Authorizing the industrial commission of Arizona to release worker compensation record, state or federal agency, institution, school or university (public or private), information service bureau, employer, or insurance company to furnish any and all background information requested by Corporate Screening Services, Inc., another outside organization acting on behalf of Employer, and/or Employer itself. I agree that a facsimile (“fax”) or photographic copy of this Authorization shall be as valid as the original.

NOTICE REGARDING BACKGROUND INVESTIGATION
PURSUANT TO CALIFORNIA LAW

Employer (Elite HR Logistics) intends to obtain information about you from an investigative consumer reporting agency and/or a consumer credit reporting

agency for employment purposes. Thus, you can expect to be the subject of “investigative consumer reports” and “consumer credit reports” obtained for employment purposes. Such reports may include information about your character, general reputation, personal characteristics and mode of living. With respect to any investigative consumer report from an investigative consumer reporting agency (“ICRA”), the Company may investigate the information contained in your employment application and other background information about you, including but not limited to obtaining a criminal record report, verifying references, work history, your social security number, your educational achievements, licensure, and certifications, your driving record, and other information about you, and interviewing people who are knowledgeable about you. The results of this report may be used as a factor in making employment decisions. The source of any investigative consumer report (as that term is defined under California law) will be Corporate Screening Services, Inc., 16530 Commerce Court, Cleveland, OH 44130, Phone: 800-229-8606, Fax: (440) 243-4204. The source of any credit report will be [add name of credit bureau].

The Company agrees to provide you with a copy of an investigative consumer report when required to do so under California law.

Under California Civil Code section 1786.22, you are entitled to find out from an ICRA what is in the ICRA’s file on you with proper identification, as

follows:

In person, by visual inspection of your file during normal business hours and on reasonable notice. You also may request a copy of the information in person. The ICRA may not charge you more than the actual copying costs for providing you with a copy of your file.

A summary of all information contained in the ICRA’s file on you that is required to be provided by the California Civil Code will be provided to you via telephone, if you have made a written request, with proper identification, for telephone disclosure, and the toll charge, if any, for the telephone call is prepaid by or charged directly to you.

By requesting a copy be sent to a specified addressee by certified mail. ICRAs complying with requests for certified mailings shall not be liable for disclosures to third parties caused by mishandling of mail after such mailings leave the ICRAs.

“Proper Identification” includes documents such as a valid driver’s license, social security account number, military identification card, and credit cards. Only if you cannot identify yourself with such information may the ICRA require additional information concerning your employment and personal or family history in order to verify your identity.

The ICRA will provide trained personnel to explain any information furnished to you and will provide a written explanation of any coded information contained in files maintained on you. This written explanation will be provided whenever a file is provided to you for visual inspection.

You may be accompanied by one other person of your choosing, who must furnish reasonable identification. An ICRA may require you to furnish a written statement granting permission to the ICRA to discuss your file in such person’s presence.

3838 Watt Ave. Suite D-404 | Sacramento, CA 95821

916-484-4300(p) | 916-484-7518(f)
www.elitehrlogistics.com 

PAGE 2 OF 16

CALIFORNIA APPLICANTS OR EMPLOYEES ONLY

By signing below, you also acknowledge receipt of the NOTICE REGARDING BACKGROUND INVESTIGATION PURSUANT TO CALIFORNIA LAW.

(Full Legal Name)

(Previous Names Used)

(Dates Used)

/

/

-

(Date of Birth)

(Social Security Number)

(Current License No.)

(State)

List all residential addresses for the last 7 years. Begin with your most current and continue on back of sheet if needed.

(Street Address)

(City)

(State & Zip)

(Street Address)

(City)

(State & Zip)

(Street Address)

(City)

(State & Zip)

(Street Address)

(City)

(State & Zip)

Have you ever been convicted of a crime other than a minor traffic violation?

Yes

No

(Offense)

(Date)

(City)

(State)

Do you have any criminal proceeding pending?

Yes

No

(Applicant Signature)

(Print Name)

(Date)

NOTICE TO DRIVERS AND DRIVER’S CERTIFICATION OF NON-MOTOR CARRIER
COMPENSATED WORK NOTICE TO DRIVERS

In accordance with Section 395.2 of the Federal Motor Carrier Safety Regulation, Title 49 of the Code of Federal

Regulations, as amended in a Final Rule issued on October 23, 1987 (53 Fed, Reg, 41717), carriers and drivers are to

include as “on-duty time

” the time a driver spends: “Performing any compensated work for any non-motor carrier

entity.”

DRIVER’S CERTIFICATION OF NONMOTOR CARRIER COMPENSATED WORK:
I hereby certify that I have read the foregoing “Notice to Drivers” and understand that any time I spend performing any compensated work for a non-motor carrier entity must be included as “on-duty time” under the federal hours of service regulation.

I further certify that: (Check appropriated box)

Currently I am NOT performing any compensated work for any motor carrier entity: In the event I do perform work for any non-motor carrier entity for which I have been or will be compensated, that I will immediately notify Elite HR Logistics, Inc. that such work has been or will be performed and will provide details on the nature of that work.

I AM performing work for a motor carrier entity for which I am being or will be compensated and have or will

provide details about the nature of that work to

(Applicant Signature)

(Print Name)

(Date)

3838 Watt Ave. Suite D-404 | Sacramento, CA 95821

916-484-4300(p) | 916-484-7518(f)
www.elitehrlogistics.com 

PAGE 3 OF 16

-

WORK EXPERIENCE

List all current and previous employment for a minimum of ten (10) years beginning with your most recent employer. Account for all periods of unemployment. Include military service and any volunteer service that is relevant to the position for which you are applying. Do not mark “See Resume”

Are you currently employed?

Yes

No

If ‘Yes’, may we contact your current employer?

Yes

No

FROM

TO

EMPLOYER

PHONE

1.

JOB TITLE

PART-TIME

FULL-TIME

ADDRESS

IMMEDIATE SUPERVISOR AND TITLE

WERE YOU SUBJECTED TO THE FEDERAL MOTOR CARRIER SAFETY REGULATIONS WHILE EMPLOYED?

YES

NO

SUMMARIZE NATURE OF WORK AND JOB RESPONSIBILITIES

2.

FROM

TO

EMPLOYER

PHONE

JOB TITLE

PART-TIME

FULL-TIME

ADDRESS

IMMEDIATE SUPERVISOR AND TITLE

WERE YOU SUBJECTED TO THE FEDERAL MOTOR CARRIER SAFETY REGULATIONS WHILE EMPLOYED?

YES

NO

SUMMARIZE NATURE OF WORK AND JOB RESPONSIBILITIES

3.

FROM

TO

EMPLOYER

PHONE

JOB TITLE

PART-TIME

FULL-TIME

ADDRESS

IMMEDIATE SUPERVISOR AND TITLE

WERE YOU SUBJECTED TO THE FEDERAL MOTOR CARRIER SAFETY REGULATIONS WHILE EMPLOYED?

YES

NO

SUMMARIZE NATURE OF WORK AND JOB RESPONSIBILITIES

4.

FROM

TO

EMPLOYER

PHONE

JOB TITLE

PART-TIME

FULL-TIME

ADDRESS

IMMEDIATE SUPERVISOR AND TITLE

WERE YOU SUBJECTED TO THE FEDERAL MOTOR CARRIER SAFETY REGULATIONS WHILE EMPLOYED?

YES

NO

SUMMARIZE NATURE OF WORK AND JOB RESPONSIBILITIES

5.

FROM

TO

EMPLOYER

PHONE

JOB TITLE

PART-TIME

FULL-TIME

ADDRESS

IMMEDIATE SUPERVISOR AND TITLE

WERE YOU SUBJECTED TO THE FEDERAL MOTOR CARRIER SAFETY REGULATIONS WHILE EMPLOYED?

YES

NO

SUMMARIZE NATURE OF WORK AND JOB RESPONSIBILITIES

3838 Watt Ave. Suite D-404 | Sacramento, CA 95821

916-484-4300(p) | 916-484-7518(f) www.elitehrlogistics.com 

PAGE 4 OF 16

REASON FOR LEAVING

REASON FOR LEAVING

REASON FOR LEAVING

REASON FOR LEAVING

REASON FOR LEAVING

	

□
□

□
□
STARTING SALARY	□	HOURLY	WAS THE JOB DESIGNATED AS A SAFETY SENSITIVE FUNCTION IN ANY DOT REGULATED MODE, SUBJECT TO					
$	□	WEEKLY		□	YES	□	NO	
			THE ALCOHOL AND CONTROLLED SUBSTANCE TESTING REQUIREMENTS?					
ENDING SALARY	□	HOURLY		
$	□	WEEKLY		

□
□

□
□
STARTING SALARY	□	HOURLY	WAS THE JOB DESIGNATED AS A SAFETY SENSITIVE FUNCTION IN ANY DOT REGULATED MODE, SUBJECT TO					
$	□			□	YES	□	NO	
		WEEKLY	THE ALCOHOL AND CONTROLLED SUBSTANCE TESTING REQUIREMENTS?					
ENDING SALARY	□	HOURLY		
$	□	WEEKLY		

□
□

□
□
STARTING SALARY	□	HOURLY	WAS THE JOB DESIGNATED AS A SAFETY SENSITIVE FUNCTION IN ANY DOT REGULATED MODE, SUBJECT TO					
$	□			□	YES	□	NO	
		WEEKLY	THE ALCOHOL AND CONTROLLED SUBSTANCE TESTING REQUIREMENTS?					
ENDING SALARY	□	HOURLY		
$	□	WEEKLY		

□
□

□
□
STARTING SALARY	□	HOURLY	WAS THE JOB DESIGNATED AS A SAFETY SENSITIVE FUNCTION IN ANY DOT REGULATED MODE, SUBJECT TO					
$	□			□	YES	□	NO	
		WEEKLY	THE ALCOHOL AND CONTROLLED SUBSTANCE TESTING REQUIREMENTS?					
ENDING SALARY	□	HOURLY		
$	□	WEEKLY		

□
□

□
□
STARTING SALARY	□	HOURLY	WAS THE JOB DESIGNATED AS A SAFETY SENSITIVE FUNCTION IN ANY DOT REGULATED MODE, SUBJECT TO					
$	□			□	YES	□	NO	
		WEEKLY	THE ALCOHOL AND CONTROLLED SUBSTANCE TESTING REQUIREMENTS?					
ENDING SALARY	□	HOURLY		
$	□	WEEKLY		

FROM

TO

EMPLOYER

PHONE

6.

JOB TITLE

PART-TIME

FULL-TIME

ADDRESS

IMMEDIATE SUPERVISOR AND TITLE

WERE YOU SUBJECTED TO THE FEDERAL MOTOR CARRIER SAFETY REGULATIONS WHILE EMPLOYED?

YES

NO

SUMMARIZE NATURE OF WORK AND JOB RESPONSIBILITIES

7.

FROM

TO

EMPLOYER

PHONE

JOB TITLE

PART-TIME

FULL-TIME

ADDRESS

IMMEDIATE SUPERVISOR AND TITLE

WERE YOU SUBJECTED TO THE FEDERAL MOTOR CARRIER SAFETY REGULATIONS WHILE EMPLOYED?

YES

NO

SUMMARIZE NATURE OF WORK AND JOB RESPONSIBILITIES

8.

FROM

TO

EMPLOYER

PHONE

JOB TITLE

PART-TIME

FULL-TIME

ADDRESS

IMMEDIATE SUPERVISOR AND TITLE

WERE YOU SUBJECTED TO THE FEDERAL MOTOR CARRIER SAFETY REGULATIONS WHILE EMPLOYED?

YES

NO

SUMMARIZE NATURE OF WORK AND JOB RESPONSIBILITIES

9.

FROM

TO

EMPLOYER

PHONE

JOB TITLE

PART-TIME

FULL-TIME

ADDRESS

IMMEDIATE SUPERVISOR AND TITLE

WERE YOU SUBJECTED TO THE FEDERAL MOTOR CARRIER SAFETY REGULATIONS WHILE EMPLOYED?

YES

NO

SUMMARIZE NATURE OF WORK AND JOB RESPONSIBILITIES

10.

FROM

TO

EMPLOYER

PHONE

JOB TITLE

PART-TIME

FULL-TIME

ADDRESS

IMMEDIATE SUPERVISOR AND TITLE

WERE YOU SUBJECTED TO THE FEDERAL MOTOR CARRIER SAFETY REGULATIONS WHILE EMPLOYED?

YES

NO

SUMMARIZE NATURE OF WORK AND JOB RESPONSIBILITIES

3838 Watt Ave. Suite D-404 | Sacramento, CA 95821

916-484-4300(p) | 916-484-7518(f) www.elitehrlogistics.com 

PAGE 5 OF 16

REASON FOR LEAVING

REASON FOR LEAVING

REASON FOR LEAVING

REASON FOR LEAVING

REASON FOR LEAVING

□
□

□
□
STARTING SALARY	□	HOURLY	WAS THE JOB DESIGNATED AS A SAFETY SENSITIVE FUNCTION IN ANY DOT REGULATED MODE, SUBJECT TO					
$	□			□	YES	□	NO	
		WEEKLY	THE ALCOHOL AND CONTROLLED SUBSTANCE TESTING REQUIREMENTS?					
ENDING SALARY	□	HOURLY		
$	□	WEEKLY		

□
□

□
□
STARTING SALARY	□	HOURLY	WAS THE JOB DESIGNATED AS A SAFETY SENSITIVE FUNCTION IN ANY DOT REGULATED MODE, SUBJECT TO					
$	□			□	YES	□	NO	
		WEEKLY	THE ALCOHOL AND CONTROLLED SUBSTANCE TESTING REQUIREMENTS?					
ENDING SALARY	□	HOURLY		
$	□	WEEKLY		

□
□

□
□
STARTING SALARY	□	HOURLY	WAS THE JOB DESIGNATED AS A SAFETY SENSITIVE FUNCTION IN ANY DOT REGULATED MODE, SUBJECT TO					
$	□			□	YES	□	NO	
		WEEKLY	THE ALCOHOL AND CONTROLLED SUBSTANCE TESTING REQUIREMENTS?					
ENDING SALARY	□	HOURLY		
$	□	WEEKLY		

□
□

□
□
STARTING SALARY	□	HOURLY	WAS THE JOB DESIGNATED AS A SAFETY SENSITIVE FUNCTION IN ANY DOT REGULATED MODE, SUBJECT TO					
$	□			□	YES	□	NO	
		WEEKLY	THE ALCOHOL AND CONTROLLED SUBSTANCE TESTING REQUIREMENTS?					
ENDING SALARY	□	HOURLY		
$	□	WEEKLY		

□
□

□
□
STARTING SALARY	□	HOURLY	WAS THE JOB DESIGNATED AS A SAFETY SENSITIVE FUNCTION IN ANY DOT REGULATED MODE, SUBJECT TO					
$				□	YES	□	NO	
	□	WEEKLY	THE ALCOHOL AND CONTROLLED SUBSTANCE TESTING REQUIREMENTS?					
ENDING SALARY	□	HOURLY		
$	□	WEEKLY		

AVAILABILITY

How were you referred to our company?

Date you are available for work:

/

/

Salary rate:

Minimum: $

/Hr

Desired: $

/Hr

Type of employment accepted:

Full-Time

Part-Time

Temporary

Temp to Hire

Direct Hire

On-Call

Hours available to work:

MONDAY

TUESDAY

WEDNESDAY

THURSDAY

FRIDAY

SATURDAY

SUNDAY

BEGINNING TIME

ENDING TIME

Commercial Driving Experience:

years

Types of Equipment Operated:

Endorsements:

All Driver Licenses Held in the past 3 years:

				

Are you able to perform the essential functions of the job for which you are applying, either with or without reasonable accommodation?

Yes

No

If no, describe the functions that cannot be performed:

Do you have any relatives employed with this company?

Yes

No

If yes, please list their names and positions:

Have you ever been convicted of a felony?
(Such conviction will not necessarily disqualify you from the position)

Yes

No

Have you ever been convicted of a misdemeanor which resulted in?

Yes

No

imprisonment within the previous 2-years

(Such conviction will not necessarily disqualify you from the position)
Give record of all High Schools, Colleges, Universities, Trade or Vocational Schools you have attended.

EDUCATIONAL BACKGROUND

3838 Watt Ave. Suite D-404 | Sacramento, CA 95821

916-484-4300(p) | 916-484-7518(f)
www.elitehrlogistics.com 

STATE

LICENSE #

CLASS

EXP DATE

STATE

LICENSE #

CLASS

EXP DATE

STATE

LICENSE #

CLASS

EXP DATE

□
□
□
□
□
□

NAME AND LOCATION	NUMBER OF YEARS
COMPLETED	MAJOR SUBJECT OR
COURSE	DEGREE OR
CERTIFICATE	
HIGH SCHOOL				
COLLEGE				
OTHER				
OTHER				

PAGE 6 OF 16

REFERENCES

List the three persons not related to you who have knowledge of your work performance within the last three years.

ACCIDENT RECORD PAST 3 YEARS

DATE OF ACCIDENT

LOCATION OF ACCIDENT

TYPE OF VEHICLE OPERATED

1..

INJURIES:

YES

NO

FMCSA/DOT DEFINED ACCIDENT:

YES

NO

DOT PREVENTABLE ACCIDENT:

YES

NO

	

2..

DATE OF ACCIDENT

LOCATION OF ACCIDENT

TYPE OF VEHICLE OPERATEDD

INJURIES:

YES

NO

FMCSA/DOT DEFINED ACCIDENT:

YES

NO

DOT PREVENTABLE ACCIDENT:

YES

NO

	

3..

DATE OF ACCIDENT

LOCATION OF ACCIDENT

TYPE OF VEHICLE OPERATED

INJURIES:

YES

NO

FMCSA/DOT DEFINED ACCIDENT:

YES

NO

DOT PREVENTABLE ACCIDENT:

YES

NO

	

License Ever Revoked or Suspended by a State of Federal Agency?

Yes

No

State or Federal Agency that suspended License

Date of Suspension:

Please provide statement of circumstances:

DRIVING EXPERIENCE

Please list the Tractors and types of equipment you have driven/pulled.

CLASS OF EQUIPMENT

TYPE OF EQUIPMENT
(VAN, TANK, FLAT, ETC)

DATES

APPROXIMATETOTALL 

FROM

TO

MILES

3838 Watt Ave. Suite D-404|I Sacramento, CA 95821

916-484-4300(p)|916-484-7518(f) www.elitehrlogistics.com 

PAGE 7 OF 16

CIRCUMSTANCESS 

EXPLANATION

CIRCUMSTANCESS 

EXPLANATION

CIRCUMSTANCESS 

EXPLANATION

NAME AND ADDRESS	OCCUPATION	NUMBER OF YEARS
KNOWN	PHONE NUMBER	

				

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PREVIOUS PRE-EMPLOYMENT DRUG & ALCOHOL INQUIRIES

Applicants Name:

By signing below I attest that I:

I HAVE NOT TESTED POSITIVE, or refused to test, on any pre-employment drug and/or alcohol test

administered by any previous potential employer that which I applied for but did not obtain a safety sensitive position or function as defined by the DOT.

I TESTED POSITIVE, or refused to test, on any pre-employment drug and/or alcohol test administered by any

previous potential employer that which I applied for but did not obtain a safety sensitive position or function as defined by the DOT.

(Applicant Signature)

(Print Name)

(Date)

APPLICANT: PLEASE READ AND SIGN BEFORE SUBMITTING THIS APPLICATION

ELITE HR LOGISTICS is an equal opportunity employer.

I authorize the above named employer and assigned agents to investigate my background to ascertain any and all information of concern to my record, whether same is of the record or not.

By signing below I authorize the above listed employer and assigned agents to investigate my background not limited to

employment history, criminal record history and drug and alcohol information. I further understand that

misrepresentation or omission of facts call for in this employment application may if hired result in termination of employment.

I acknowledge that any employment offered by the employer has no specified term and may be terminated by the employer or the employee at will with or without cause. I further acknowledge that this at will statement is not alterable except by a written agreement signed by the company president and myself.

Our company is an Equal Employment Opportunity Employer, which prohibits discrimination against any employee or applicant for employment because of race, color, religion, sexual orientation, age, handicap or status as a disabled veteran or veteran of the Vietnam War. I hereby certify that I have not knowingly withheld any information that may adversely affect my chances for employment and that the answers given by me are true and correct to the best of my knowledge. I further certify that I, the undersigned applicant have personally completed this application. I understand that any omission or misstatement of material facts on this application or on any document used to secure the employment shall be grounds for rejection of this application or for the immediate discharge if I am employed, regardless of the time elapsed before discovery.

I certify that this application was completed by me and that all entries on it and information documented by the applicant are true and complete,

I HAVE READ AND UNDERSTAND ALL OF THE CONDITIONS UPON WHICH THIS OFFER OF EMPLOYMENT IS

MADE.

(Applicant Signature)

(Print Name)

(Date)

3838 Watt Ave. Suite D-404 | Sacramento, CA 95821

916-484-4300(p) | 916-484-7518(f)
www.elitehrlogistics.com 

PAGE 8 OF 16

ATTENTION COMMERCIAL DRIVERS

According to Sections 391.43 and 649-F of the Federal Motor Carrier Safety Regulations, Elite HR Logistics is required to keep a copy of all commercial drivers’ Medical Examination Reports in their DOT file. If the driver does not provide this form, the cost of obtaining it will be debited from their paycheck.

(Applicant Signature)

(Print Name)

(Date)

ACKNOWLEDGEMENT OF AVAILABLE MODIFIED DUTY

Elite HR Logistics desires to provide our injured employees with the most expedient and quality medical care for their

work related injuries.

Elite HR Logistics has developed a modified duty program that will allow our injured workers to return to work on a modified duty status by making accommodations for any work restrictions as outlined by a company authorized physician.

I understand that failure to report for modified duty will be considered an unexcused absence, and I will not be paid for any days missed.

(Applicant Signature)

(Date)

(Recruiter Signature)

(Date)

ACKNOWLEDMENT OF FEDERAL MOTOR CARRIER SAFETY REGULATIONS

To maintain compliance with section 395 of the Federal Motor Carrier Safety Regulations, drivers are required to turn in all time exemption logs / timecards as well as log books filled out in accordance with Federal Motor Carrier Safety Regulations in order to have your check released to you. If these are not turned in Elite HR Logistics will hold your check until we receive the documents we are required to have. If documents are turned in, but not completed correctly, we will provide you with any and all training necessary to be compliant with the Federal Motor Carrier Safety Rules.

I understand that this is a condition of my employment with Elite HR Logistics and the Federal Motor Carrier Safety Regulations.

(Applicant Signature)

(Date)

(Recruiter Signature)

(Date)

CERTIFICATION OF ROAD TEST

Instructions to Carrier; If the road test is successfully completed, the person who gave it must complete this certificate of road test in duplicate, retain the original in the files of the employing carrier, and provide a copy to the person examined. (see 391.31 © (f) (g) (1) (2) of the Motor Carrier Safety Regulations)

-

(Driver’s Name)

(Social Security Number)

(Operator’s or chauffeur’s License No.)

(State)

(Type of Power Unit)

(Type of Trailer(s))

This is to certify that the above-named driver was given a road test under my supervision on

, 20

consisting of approximately

miles of driving.

It is my considered opinion that this driver possesses sufficient driving skill to operate safely the type of commercial motor vehicle listed above.

(Signature of Examiner)

(Title)

(Organization and Address of Examiner)

3838 Watt Ave. Suite D-404 | Sacramento, CA 95821

916-484-4300(p) 916-484-7518(f)
www.elitehrlogistics.com 

PAGE 9 OF 16

-

I have read and understand the above information regarding my Medical Examination Report, and I understand that, in signing below, I am agreeing to allow Elite HR Logistics to debit the cost of obtaining my Medical Examination Report out of my paycheck.

MOTOR VEHICLE DRIVER’S CERTIFICATION VIOLATION AND REVIEW RECORD

(Driver Name)

(Location)

I.

CERTIFICATION OF VIOLATIONS
I certify that the following is a true and complete list of traffic violations and accidents (other than parking

violations) for which I have been involved in, during the past twelve (12) months.

				

				

If no violations are listed above, I certify that I have not been convicted or forfeited bond or collateral on account of any violation required to be listed during the past 12 months. I hereby authorize my employer to contact any State Agency to acquire a Motor Vehicle Record, and that said record be made part of my Driver’s Qualification File.

(Applicant Signature)

(Print Name)

(Date)

II.

REVIEW AND EVALUATION OF DRIVER’S RECORD
In accordance with Section 391.25, Motor Carrier Safety Regulations, all information pertinent to the above driver’s safety of operations, including the list of violations furnished by him in accordance with Section 391.27

has been reviewed for the past twelve (12) months.

ACTION TAKEN:

(Motor Carrier’s Name)

(Address)

(Reviewed-By Signature)

(Title)

(Date)

DRIVERS STATEMENT OF ON-DUTY HOURS (FOR NEWLY HIRED DRIVERS)

-

(Driver’s Name)

(Social Security Number)

(License No.)

(State)

(Endorsements)

(Restrictions)

(Class)

HOURS WORKED

TOTAL HOURS

I hereby certify that the information given above is correct to the best of my knowledge and belief, and that I was last

Relived from work at: TIME

AM or PM ON (date)

(Applicant Signature)

(Print Name)

(Date)

3838 Watt Ave. Suite D-404 | Sacramento, CA 95821

916-484-4300(p) 916-484-7518(f)
www.elitehrlogistics.com 

PAGE 10 OF 16

DATE

OFFENSE

LOCATION

TYPE OF VEHICLE OPERATED

DATE

OFFENSE

LOCATION

TYPE OF VEHICLE OPERATED

DATE

OFFENSE

LOCATION

TYPE OF VEHICLE OPERATED

DATE

OFFENSE

LOCATION

TYPE OF VEHICLE OPERATED

																															

    -

DAY	1
(Yesterday)	2	3	4	5	6	7	
DATE								

INSTRUCTIONS: Motor carriers when using a driver for the first time shall obtain from the driver a signed statement giving the total time on-duty during the immediately preceding 7 days and time at which such driver was last relieved from duty prior to beginning work for such carrier. Rule 395.8(j)(2) Federal Motor Carrier Safety Regulations. NOTE: Hours for any compensated work during the preceding 7 days, including work for a non-motor carrier entity, must be recorded on this form.

REQUEST FOR CHECK OF DRIVING RECORD

I herby authorize you to release the following information to Elite HR Logistics for the 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.

(Applicant Signature)

(Print Name)

(Date)

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 II, Subtitle D, Chapter 1, of Public Law 104-208), I 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 herby certify that this report request and the above applicant’s release notice meet the definition of “permissible ” of state motor vehicles records under the provisions of the Driver’s Privacy Protection Act of 1994 (Public Law

uses

103-322, Title XXX, Section 300002(a)).

(Signature of Requester)

(Date)

TO:

DEAR SIR/MADAM:

The following named person has made application with our company for the position of

In accordance with Section 391.23, Federal Department of Transportation Regulations, please furnish the undersigned with the applicant’s driving record for the past three years.

The following named person has made application with our company for the position of

In accordance with Section 391.25, Federal Department of Transportation Regulations, please furnish the undersigned with the applicant’s driving record for the past year.

-

(Driver’s Name)

(Social Security Number)

(Date of Birth)

(License No.)

(State)

(Current Street Address)

(City)

(State & Zip)

(Former Street Address)

(City)

(State & Zip)

REQUESTED BY

Elite HR Logistics

3838 Watt Ave Suite D-404

Sacramento, Ca 95821

(Requester Signature)

(Requester Print Name)

(Requester Title)

3838 Watt Ave. Suite D-404 | Sacramento, CA 95821

916-484-4300(p) 916-484-7518(f)
www.elitehrlogistics.com 

PAGE 11 OF 16

□

□

-

DRIVER RECEIPT OF DOT DRUG AND ALCOHOL EDUCATIONAL MATERIALS

INSTRUCTIONS: [382.601] DOT requires the company to provide all company drivers with educational material regarding drug and alcohol use and abuse, and the rules and regulations of DOT which apply to the Company’s drivers. Each representative of a driver organization is also required to receive this information. This form should be used to document receipt of the required materials.

To the Drivers: DOT requires that each driver and/or organization must sign this form certifying receipt of these materials. Any driver refusing to sign this form will be considered insubordinate and subject to discipline. The original of this form will be retained for an indefinite time period in a separate file along with other company records maintained on the DOT drug and alcohol testing program. Drivers may request a copy of this certification.

DRIVER’S CERTIFICATION:

The undersigned hereby certifies that he/she received the educational materials which the Company is required to provide me in accordance with 49 C.F.R. 382.601. I acknowledge and agree that I am responsible for reading, understanding and obeying all Company policies and DOT regulations regarding alcohol and drug use testing. I also understand that, because changes in the governing federal law or regulations may occur from time to time, terms and conditions of the Company’s policy may also change without the Company being able to give me prior notice. Nonetheless, I agree to comply with the DOT’s regulations and the Company’s policies regarding drug and alcohol use and testing. I further understand and agree that I may be subject to disciplinary action and other liability for violating DOT’s regulations and/or the Company’s policies. I have been advised any questions with regard to these materials should be addressed to the Corporate Safety Director.

Prior to signing this Receipt, I read it carefully and had an opportunity to ask questions regarding its content.

(Applicant Signature)

(Print Name)

(Date)

Elite HR Logistics agrees to pay all fees for a DOT or pre-employment drug screen with the following exceptions: If any employee No Shows/No Calls* on any day within the first week of an ongoing assignment and cannot furnish information as to why no attempt was made to contact Elite HR Logistics or the Client Company; also if you Fail a drug screen, 100% of the drug screen fee will be deducted from his/her wages.

* No Shows/No Calls being defined as not reporting to work as scheduled or not calling in un-available to Elite HR Logistics or to the Client Company prior to the scheduled day of work.

I agree to the above agreement and the exception to the agreement.

(Applicant Signature)

(Print Name)

(Date)

3838 Watt Ave. Suite D-404 | Sacramento, CA 95821

916-484-4300(p) | 916-484-7518(f)
www.elitehrlogistics.com 

PAGE 12 OF 16

NOTICE TO DRIVERS AND CERTIFICATE OF COMPLIANCE

I.

NOTICE TO DRIVERS

The Commercial Motor Vehicle Safety Act of 1986 provides for a new set of controls over the drivers of commercial vehicles. The new law applies to all drivers operating vehicles and combinations with a Gross Vehicle Weight Rating over 26,000 pounds, and to any vehicle, regardless of weight, transporting hazardous materials.

The following provision of this legislation became effective July 1, 1987:

1. No driver may possess more than one license, and no motor carrier may use a driver having more than

one license. A limited exception is made for drivers who are subject to non-resident licensing requirements of any state. This exception does not apply after December 31, 1989.

2. A driver convicted of a traffic violation (other than parking) must notify the motor carrier and the state which issued the license to that driver of such convictions within 30 days.

previous employment as the driver of a commercial vehicle for the past 10 years, in addition to any other required information about the applicant’s employment history.

4. Any violation is punishable by a fine not to exceed $25,500. In addition, the Federal Motor Carrier

Safety Regulations now require that a driver who loses any privilege to operate a commercial vehicle or who is disqualified from operating a commercial vehicle, must notify the motor carrier the next business day after receiving notification of such action.

II.

CERTIFICATION BY DRIVER

I hereby certify that I have read and understand the driver provisions of the Commercial Motor Vehicle Safety Act of 1986, which became effective on July 1, 1987.

-

(Driver’s Name)

(Social Security Number)

(License No.)

(Class)

(State)

(Street Address)

(City)

(State & Zip)

I further certify that the above commercial vehicle license is the only one held: or that I have surrendered the following licenses to the state indicated.

(License No.)

(Class)

(State)

(License No.)

(Class)

(State)

(Applicant Signature)

(Print Name)

(Date)

3838 Watt Ave. Suite D-404 | Sacramento, CA 95821

916-484-4300(p) | 916-484-7518(f)
www.elitehrlogistics.com 

PAGE 13 OF 16

-

3. Any person applying for a job as commercial vehicle driver must inform the prospective employer of all

MEDICAL EXAMINATION REPORT

FOR COMMERCIAL DRIVER FITNESS DETERMINATION

1.

DRIVER’S INFORMATION

DRIVER’S NAME (LAST, FIRST, MIDDLE)

NEW CERTIFICATION

RECERTIFICAIOTN

FOLLOW UP

DATE

SOCIAL SECURITY NUMBER

DATE OF BIRTH

AGE

MALE

FEMALE

SEX

DRIVER LICENSE NO.

LICENSE CLASS

STATE OF ISSUE

STREET ADDRESS

STATE

ZIP

2.

HEALTH HISTORY

YES

NO – Any illness or injury in the last 5 years?

YES

NO – Head/Brain injuries, disorders or illnesses

YES

NO – Seizures, epilepsy

Medication

YES

NO – Eye disorders or impaired vision (except corrective lenses)

YES

NO – Ear disorders, los of hearing or balance

YES

Medication

YES

NO – Heart surgery (valve replacement/bypass, angioplasty, pacemaker)

YES

NO – High blood pressure

Medication

YES

NO – Muscular disease

YES

NO – Shortness of breath

YES

NO – Lung disease, emphysema, asthma, chronic bronchitis

YES

NO – Kidney disease, dialysis

YES

NO – Liver disease

YES

NO – Digestive problems

YES

NO – Diabetes or elevated blood sugar controlled by:

Diet

Pills

Insulin

YES

Medication

YES

NO – Loss of, or altered consciousness

YES

NO – Fainting, dizziness

YES

NO – Sleep disorders, pauses in breathing while asleep, daytime sleepiness, loud snoring

YES

NO – Stroke or paralysis

YES

NO – Missing or impaired hand, arm, foot, leg, finger, toe

YES

NO – Spinal injury or disease

YES

NO – Chronic low back pain

YES

NO – Regular, frequent alcohol use

YES

NO – Narcotic or habit forming drug use

FOR ANY YES ANSWER, INDICATE ONSET DATE, DIAGNOSIS, TREATING PHYSICIAN’S NAME AND ADDRESS, AND ANY CURRENT LIMITATION. LIST ALL MEDICATIONS (INCLUDING OVER THE COUNTER MEDICATIONS) USED REGULARLY OR RECENTLY

I certify that the above information is complete and true. I understand that inaccurate, false or missing information may invalidate the examination and my Medical Examiner’s Certificate.

(Applicant Signature)

(Print Name)

(Date)

3838 Watt Ave. Suite D-404 | Sacramento, CA 95821

916-484-4300(p) | 916-484-7518(f)
www.elitehrlogistics.com 

PAGE 14 OF 16

□
□
□

//

□
□

□

□
□

NO – Heart disease or heart attack; other cardiovascular condition

□

□
□

APPLICANT NAME

 	SOCIAL SECURITY NUMBER

                      -                  -	

I hereby authorize my previous employers to release any and all information to ELITE HR LOGISTICS, INC, concerning my performance, conduct, accident record and all required DOT drug and alcohol related information while previous employed as a commercial motor vehicle operator in the previous 3 years from the date of this form as specified and required by the Federal Motor Carrier Safety Regulations, Part 391.23 investigation and inquiries.

APPLICANT SIGNATURE

		DATE

	

PREVIOUS COMPANY NAME	The information requested is required by Part 391.23 for the U.S. Department of Transportation Motor Carrier Safety Regulations.
	
STREET	CITY	STATE 	ZIP		
SUPERVISORS NAME	TELEPHONE #		
PERIOD OF EMPLOYMENT
FROM _______/_______        TO_______/_______
              MO.         YR.                           MO.         YR.	POSITION HELD		

TO FORMER EMPLOYER: Please give the following information about this applicant. It will be held in strict confidence.

      Description 	          Excellent		Good      		  Fair			    Poor	
Quality of Work					
Cooperation with others					
Safety habits					
Driving Skills					
Attendance Record					

1.  Is employment record with your Company correct? 									
2.  Driver was subject to DOT testing requirements From: ________________To: ________________________________
3.  Why did applicant leave?												
4.  If Company policy allowed, would you rehire?										
5.  Did he have custody of money or valuables?										
6.  Qualified in what equipment?												
7.  How many total accidents?			 How many FMCSA defined recordable accidents?			
8.  Driver’s license ever revoked or suspended?										
COMMENTS:															
Yes    No     DOT/FMCSA Previous Employer 3-year Drug and Alcohol Investigation and Inquiry
		1. Did the employee have an alcohol test with results greater than 0.04 BAC?	
		2. Did the employee have a verified positive test result?	
		3. Did this employee refuse to be tested?	
		4. Did the employee have any other violation of the DOT/FMCSR drug and alcohol testing regulations?	
		5. Did the employee report any drug and alcohol rule violations to you?	
		6. If you answered yes to any of the above items, did the employee complete a SAP program and return to duty test?	
		7. If answered yes to item #6 please transmit the employees SAP reports, return to duty documentation and any and all follow-up test information or records.	
		8. This Company did not have a DOT drug/alcohol program during this period.	

__________________________________   __________________________________   __________________________________   _____________  
	(Signature)	(Printed Name)	(Title)	(Date)

Date Sent/Initial	2nd Request/Date Initial	3rd Request/Date Initial	

dot/fmcsa previous employment investigations and inquiries

PAGE 15 OF 16

The prospective employer must expressly notify drivers with Department of Transportation regulated employment during the preceding three years via the application form or other written document prior to any hiring decision? that he or she has the following rights regarding the investigative information that will be provided to the prospective employer pursuant to paragraphs (d) and (e) of this section: 
(i) The right to review information provided by previous employers; 
(ii) 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; 
(iii) 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. 
(2) Drivers who have previous Department of Transportation regulated employment history in the preceding three years, and wish to review previous employer-provided investigative information 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 (5) 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 (30) 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.

DRIVER’S POLICY

 

(j) (1) Drivers wishing to request correction of erroneous information in records received pursuant to paragraph 
(i) of this section must send the request for the correction to the previous employer that provided the records to the prospective employer. 
(2) After October 29, 2004, 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 correct the data. 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. 
(3) Drivers wishing to rebut information in records received pursuant to paragraph (i) of this section must send the rebuttal to the previous employer with instructions to include the rebuttal in that driver's safety performance history. 
(4) After October 29, 2004, within five business days of receiving a rebuttal from a driver, the previous employer must: 
(i) Forward a copy of the rebuttal to the prospective motor carrier employer; 
(ii) Append the rebuttal to the driver's information in the carrier's appropriate file, to be included as part of the response for any subsequent investigating prospective employers for the duration of the three-year data retention requirement. 
(5) The driver may submit a rebuttal initially without a request for correction, or subsequent to a request for correction. 
(6) The driver may report failures of previous employers to correct information or include the driver's rebuttal as part of the safety performance information, to the FMCSA following procedures specified at § 386.12 . 

PAGE 16 OF 16

(k)(1) The prospective motor carrier employer must use the information described in paragraphs (d) and (e) of this section only as part of deciding whether to hire the driver. 
(2) The prospective motor carrier employer, its agents and insurers must take all precautions reasonably necessary to protect the records from disclosure to any person not directly involved in deciding whether to hire the driver. The prospective motor carrier employer may not provide any alcohol or controlled substances information to the prospective motor carrier employer's insurer. 
(l)(1) No action or proceeding for defamation, invasion of privacy, or interference with a contract that is based on the furnishing or use of information in accordance with this section may be brought against? 
(i) A motor carrier investigating the information, described in paragraphs (d) and (e) of this section, of an individual under consideration for employment as a commercial motor vehicle driver, ii) A person who has provided such information; or 
(iii) The agents or insurers of a person described in paragraph (l)(1)(i) or (ii) of this section, except insurers are not granted a limitation on liability for any alcohol and controlled substance information. 
(2) The protections in paragraph (l)(1) of this section do not apply to persons who knowingly furnish false information, or who are not in compliance with the procedures specified for these investigations. (Approved by the Office of Management and Budget under control number 2126?0004)