California applicants or employees only

I have received the following training and understand and acknowledge the company policies and procedures listed below. I further acknowledge that if I have any questions, I can contact Desiree Caldwell at ELITE HR LOGISTICS, INC at (916) 484-4300.
INJURY & ILLNESS PREVENTION PROGRAM
TRAINING TOPIC	DATE COMPLETED	TRAINER’S INITIALS	EMPLOYEE’S INITIALS	
COMPANY POLICIES				
HAZARDOUS COMMUNICATIONS				
LOCKOUT/TAGOUT				
INTRODUCTION TO FORKLIFT				
FIRE SAFETY				
FALL PROTECTION				
POWER TOOLS				
EXIT INTERVIEW				

_______________________________   _______________	_______________________________   _______________
	(Applicant Signature)	(Date)	(Recruiter Signature)	 (Date)

CELL PHONE POLICY

Clients of ELITE HR LOGISTICS, INC will in some instances issue selected employees a company cell phone, as appropriate to your duties and responsibility to facilitate communications with clients and or customers. 

You must abide by the following at all times:

•	Cell phones are for company business use only.

•	No personal phone calls are ever to be made from or to your company issued phone.

•	Any phone calls deemed “personal” by the client, will be automatically deducted from your next paycheck after notice of the deduction.

•	As of July 2008, it is illegal to use your cell phone with out a hands free device while driving. Neither ELITE HR LOGISTICS, INC nor its clients will pay for any fines accrued by violating the cell phone law. 

•	All cell phones, chargers and/or accessories assigned to employees must be surrendered to the company upon termination or extended absence. Failure to return assigned items will result in 100% of the replacement cost to be deducted from the employee’s next/final paycheck.

Any violation of this policy could result in immediate disciplinary action including, but not limited to termination of employment.

By signing below you acknowledge you have read, understand and will abide by the above stated.

_______________________________   _______________	_______________________________   _______________
	(Applicant Signature)	(Date)	(Recruiter Signature)	 (Date)

ELITE HR LOGISTICS, INC has developed these safety rules patterned after the Federal OSHA requirements. Read and become familiar with these rules and other safety rules that apply to your job. 

code and safe practices

1.	Report an injury to your supervisor immediately.
2.	Report any observed unsafe condition to your supervisor. 
3.	Horseplay is prohibited at all times.
4.	The drinking of alcoholic beverages is not permitted on the job. Any employee discovered under the influence of alcohol or drugs will not be permitted to work. 
5.	If you do not have current First Aid Training, do not move or treat an injured person unless there exists an immediate threat such as fire or explosion.
6.	If there exists the hazard of falling objects, an approved hard hat must be worn. 
7.	Appropriate clothing and footwear must be worn on the job at all times. 
8.	You should not perform any task unless you are trained to do so and are aware of the hazards associated with that task. 
9.	You may be assigned certain personal protective safety equipment. This equipment should be available for use on the job, be maintained in good condition, and worn when required.
10.	Learn safe work practices. When in doubt about performing a task safely, contact your supervisor for instruction and training. 
11.	The riding of a hoist hook or on other equipment not designed for such purposes is prohibited at all times. 
12.	Never remove or bypass safety devices. 
13.	Do not approach operating machinery from the blind side; let the operator see you. 
14.	Learn where fire extinguishers and first aid kits are located.
15.	Maintain a general condition of good housekeeping in all work areas at all times. 
16.	Obey all traffic regulations when operating any vehicle. If you receive a traffic violation of any kind, you are to report it to Elite HR Logistics immediately. 
17.	When operating or riding in company vehicles, or using your personal vehicle for business purposes, the vehicle’s seatbelt shall be worn. 
18.	Be alert to hazards that could affect you and your co-employees. 
19.	Obey safety signs and tags.  
20.	Always perform you assigned task in a safe and proper manner; do not take shortcuts. The taking of shortcuts and the ignoring of established safety rules is a leading cause of employee injury. 

I certify that I have read, understand and will abide by the above listed safety rules. Failure to do so may be grounds for termination and may disqualify my insurance benefits. 

acknowledgement of receipt and review of code and safe practices

TO ALL EMPLOYEES:

Attached is a copy of the code of safe practices. These guidelines are provided for your safety. 

It is the responsibility of ELITE HR LOGISTICS, INC to provide and review this code with each employee. It is the Employee’s responsibility to read and comply with this code. 

I certify that I have read, understand and will abide by the above listed safety rules. Failure to do so may be grounds for termination and may disqualify my insurance benefits. 

I HAVE READ AND UNDERSTAND THE CODE OF SAFE PRACTICES.  

__________________________________   ___________________________________   _________________________
	(Applicant Signature)	 (Print Name) 	(Date)
EMPLOYEE CONSENT FOR SUBMISSION BAT AND/OR URINALYSIS COLLECTION, TESTING, AND RELEASE OF INFORMATION FORM

california drug testing associates

ELITE HR LOGISTICS, INC has requested that I provide urine and/or breathe sample and consent to the testing of said urine and/or breathe for the presence of drugs and/or alcohol. 

As a condition of employment, I ________________________________ agree to provide urine and/or breath specimen(s) and agree that it may be tested for drugs and/or alcohol. 

1.	I authorize California Drug Testing associates (Collection Facility) and Quest (Laboratory) to determine the presence and/or level of said drugs in the body fluid(s) specimen(s) provided by me.

2.	I further give my consent to ELITE HR LOGISTICS, INC to release to it’s designated agent(s) the results of any laboratory tests performed by Quest (Laboratory) to determine the presence and/or level of said drugs in the body fluid(s) specimen(s) provided by me.

3.	I realize that if drugs and/or alcohol are found to be present in my body fluid(s) or breath, such findings will result in action up to and including termination. 

4.	I realize that if I refuse to provide a body fluid specimen(s) or breath analysis and/or refuse to consent to it’s testing for drugs and/or alcohol, my continued employment will be subject to action up to and including termination.

5.	I agree to hold harmless the collection facility, the laboratory, all physicians, employees and agents who work or perform services for the above organizations from any actions that may arise out of such test results being divulged to ELITE HR LOGISTICS, INC or it’s designated agent(s). 

_________________________   ____-____-____   ___________	__   _______________________   _______________
	(Applicant Signature) 	(SSN)	(Date)	(Recruiter Signature)	 (Date)

employee substance abuse policy

The policy of the Company is to maintain a drug and alcohol free work environment that is safe and productive for our employees and others having business with our Company. To meet these objectives, the following policy has been adopted. 

The unlawful use, possession, purchase, sale, distribution or being under the influence of any illegal drug and/or the misuse of legal drugs while on Company or Client premises or while performing services for our Company or Client is strictly prohibited. The Company also prohibits reporting to work or performing services while impaired by the use of alcohol or consuming alcohol while on duty. 

In order to ensure compliance with this policy, substance abuse screening may be conducted in the following situations:

Pre-Employment:	As may be required/requested by our Company or clients.

For Cause:		Upon reasonable cause to believe that a substance abuse problem exists, 
			testing may be conducted.

Random:		Unannounced random selection of employees may be performed.

Post Accident:		Any employee involved in an accident/injury while performing services
			for our Company or client that results in property damage or bodily injury
			requiring medical treatment will be required to submit to a substance abuse
			screening. 

Compliance with this policy is a condition of employment. Employees who test positive or who refuse to submit to substance abuse screening will be subject to termination. 

Notwithstanding any provision herein, this policy will be enforced at all times in accordance with applicable State laws. 

_______________________________   _______________	_______________________________   _______________
	(Applicant Signature)	(Date)	(Recruiter Signature)	 (Date)

Initials

Policies and procedures

	1.	I am telephone accessible and I have reliable transportation.	
	2.	I understand that I am expected to complete any job assignment I accept. If I do not complete the assignment, then ELITE HR LOGISTICS, INC can assume I voluntarily quit.	
	3.	I understand that I am an employee of ELITE HR LOGISTICS, INC and only I or ELITE HR LOGISTICS, INC can terminate my employment. When an assignment ends I must report to ELITE HR LOGISTICS, INC for my next job assignment. Failure to do so or to accept my next job assignment will indicate that I have voluntarily quit and will not be eligible for unemployment benefits.	
	4.	ELITE HR LOGISTICS, INC has a very strict “NO DRUG POLICY”, and I have signed a consent form to submit to drug testing. I understand that my failure to comply with this agreement will be grounds for my immediate termination. 	
	5.	When there reasonable suspicion that I may possess illegal contraband I will be required to submit to myself, my personal property and anything of mine on company property or in the company truck to search and seizure. Refusal to consent to search will result in termination.	
	6.	Once I have accepted a job, I must report to ELITE HR LOGISTICS, INC office to pick up a time sheet. Unless special arrangements have been made, I understand ELITE HR LOGISTICS, INC will not recognize of pay for any hours worked by an employee in the absence of an individual time ticket signed by both the client and the employee. 	
	7.	If for some unexpected reason, such as an emergency or illness, I cannot make it to work or will be late, I will contact ELITE HR LOGISTICS, INC two hours prior to start time so you can call the client and/or find a replacement. My failure to do so may be grounds for dismissal and/or indicate that I have quit.	
	8.	If I sustain an injury/accident on the job, I will inform the client and ELITE HR LOGISTICS, INC immediately after the accident. ELITE HR LOGISTICS, INC will coordinate with the client and me the proper procedure for treatment and reporting of the accident. Failure to so will result to disciplinary action and may lead to termination.	
	9.	I understand and will comply with ELITE HR LOGISTICS, INC Safety Rules and Regulations and Hazardous Communications program explained to me in ELITE HR LOGISTICS, INC orientation. 	
	10.	ELITE HR LOGISTICS, INC pays employees once a week. Our pay period starts on Monday and ends on Sunday. My check will be ready after 10:00 AM the Friday following the week worked (unless other arrangements have been made). 	
	11.	I understand that in order to be paid in a timely manner, time tickets must be turned in no later than 9:00 AM each Monday following the week worked. Any late tickets will not be paid until the next payroll (next week). 	
	12.	By initialing I voluntarily forfeit my lunch period if I am on duty less than 6 hours.	
	13.	I am aware after 6 hours on duty it’s required that I take a 30 minute lunch period. Failure to do so may lead to disciplinary action up to termination.	
	14	I have received a pamphlet explaining my rights and obligations in relation to Workers Compensation Insurance in the State of California. 	
	15.	I have read and fully understand the above statements regarding ELITE HR LOGISTICS, INC policies and procedures and agree to the same. I understand that failure to comply with these policies and procedures could lead to my termination and may jeopardize my insurance benefits. 	
	16.	I understand that any physical threats of violence will result in immediate termination.	
_______________________________   _______________	_______________________________   _______________
	(Applicant Signature)	(Date)	(Recruiter Signature)	 (Date)

Job description for Semi/Bobtail Truck Drivers

Prerequisite for hiring

•	Possess a Valid Class A or B license
•	Submit a clean D.M.V. printout not older than 30 days
•	Provide past employer references
•	Have a current medical card
•	Submit to a D.O.T. urine test for the presence of illegal drugs (randomly and/or yearly)
•	Must have a neat and clean appearance
•	Customer service skills must include good English, written and oral
•	Must have ability to work with little or no supervision
•	Must have ability to operate semi tractor-trailer and bobtail, as well as an in-depth understanding of all vehicle codes related to heavy equipment

Physical Demands

•	Must be able to drive for long periods at a time as well as the physical demands associated with driving a semi tractor-trailer and bobtails: Bend, Stoop, Push/Pull.

Job Description

•	Clock in and out when appropriate for your shift of work
•	Complete a daily pre-trip inspection form and follow up with maintenance requirements
•	Fuel vehicle and check/add fluids as necessary
•	Insure that all paperwork is correct and on board vehicle before leaving
•	Deliver and pick up vehicles at contracted maintenance facility when appropriate
•	Insure that the transportation manager is aware of all maintenance required for vehicles as well as any and all equipment related to job (i.e. loading straps, dock plates, etc.)
•	Maintain a safe and courteous driving record; if you receive a traffic violation of any kind, you are to report it to Elite HR Logistics immediately. 
•	Maintain rapport with clients which includes friendly and courteous service

ELITE HR LOGISTICS, INC is a client driven company. Drivers should maintain a “Company Representative” appearance and attitude. Remember the clients will see you on a regular basis and any and all action you display will reflect that of ELITE HR LOGISTICS, INC. The ability to work will with others in a courteous manner is highly looked upon as well as completing the job in a timely and safe fashion. 

__________________________________   ___________________________________   _________________________
	(Applicant Signature)	 (Print Name) 	(Date)

EMPLOYER PULL NOTICE PROGRAM

 

AUTHORIZATION FOR
RELEASE OF DRIVER RECORD INFORMATION

I,________________________________________, California Driver License Number, _________________________, hereby authorize the California Department of Motor Vehicles (DMV) to disclose or otherwise make available, my driving record, to my employer, ELITE HR LOGISTICS, INC, INC.

I understand that my employer may enroll me in the Employer Pull Notice (EPN) program to receive a driver record report at least once every twelve (12) months or when any subsequent conviction, failure to appear, accident, driver’s license suspension, revocation, or any other action is taken against my driving privilege during my employment.

I am not driving in a capacity that requires mandatory enrollment in the EPN program pursuant to California Vehicle Code (CVC) Section 1808.1(k). I understand that enrollment in the EPN program is in an effort to promote driver safety, and that my driver license report will be release to my employer to determine my eligibility as a licensed driver for my employment.

EXECUTED AT: CITY                                                          COUNTY                                                                             STATE
SACRAMENTO                                                  SACRAMENTO                                                    CA	

DATE	SIGNATURE AND TITLE OF EMPLOYEE

X	

I, ________________________________________________, of ELITE HR LOGISTICS, INC do hereby certify under penalty of perjury under the laws in the State of California, that I am an authorized representative of this company, that the information entered on this document is true and correct, to the best of my knowledge and that I am requesting driver record information on the above individual to verify the information as provided by said individual. This record is to be used by this employer in the normal course of business and as a legitimate business need to verify information relating to a driving position not mandated pursuant to CVC section 1808.1. The information received will not be used for any unlawful purpose. I understand that if I have provided false information, I may be subject to prosecution for perjury (Penal Code Section 118) and false representation (CVC Section 1808.45). These are punishable by a fine not exceeding five thousand dollars ($5,000) or by imprisonment in the county jail not exceeding one year, or both fine and imprisonment. I understand and acknowledge that any failure to maintain confidentiality is both civilly and criminally punishable pursuant to CVC Sections 1808.45 and 1808.46.

EXECUTED AT: CITY                                                          COUNTY                                                                             STATE
SACRAMENTO                                                  SACRAMENTO                                                    CA	
DATE	SIGNATURE AND TITLE OF AUTHORIZED REPRESENTATIVE
X	

To obtain a driver record on a prospective employee you may submit an INF 1119 form. To add this driver to the EPN Program you must submit the applicable forms: INF 1100, INF 1102, INF 1103, INF 1103A form. You may obtain forms at our website at www.dmv.ca.gov/otherservices, or by calling 916-657-3646. 

THIS FORM MUST BE COMPLETED AND RETAINED AT THE EMPLOYER’S PRINCIPAL PLACE OF BUSINESS AND MADE AVAILABLE UPON REQUEST TO DMV STAFF.

DO NOT RETURN THIS FORM TO DMV.

skills/availability/area knowledge checklist

 

WAREHOUSE		CLASS A DRIVER		CLASS B DRIVER		CLASS C DRIVER	
ASSEMBLER		48 TRAILER		PASSENGER		BOBTAIL	
FL SITDOWN-BEG		53 TRAILER		BOBTAIL		BOXTRUCK	
FL SITDOWN-KNOW		DOUBLES-BEG		BOXTRUCK		AIRBREAKS	
FL SITDOWN-EXP		DOUBLES-KNOW		AIRBREAKS		BILINGUAL	
FL STAND UP-BEG		DOUBLES-EXP		BILINGUAL		LOAD/UNLOAD	
FL STAND UP-KNOW		FLATBED-BEG		LOAD/UNLOAD		MAP READING	
FL STAND UP-EXP		FLATBED-KNOW		MAP		FLATBED-BEG	
LABORER		FLATBED-EXP		FLATBED-BEG		FLATBED-KNOW	
BILINGUAL		TARPING		FLATBED-KNOW		FLATBED-EXP	
LOAD/UNLOAD		STRAPPING-BINDER		FLATBED-EXP		ROUTE DELIVERY	
PRODUCTION		STRAPPING-CHAINS		ROUTE DELIVERY		BAY AREA	
RECEIVING		HAZ-MAT		HAZ-MAT		HAZ-MAT	
SUPERVISOR		BILINGUAL		SNOW/ICE		SNOW/ICE	
50 LBS-LIFTING		LTL		50LBS-LIFTING		50LBS-LIFTING	
75 LBS-LIFTING		LOAD/UNLOAD		75LBS-LIFTING		75LBS-LIFTING	
100 LBS-LIFTING		MAP READING		100LBS-LIFTING		100LBS-LIFTING	
FURN. ASSEMBLY		MERCHANDISER		BAY AREA			
HAND TOOLS		OTR		TWIC		AREA	
INVENTORY		PIGGY-FKLFT				BAY AREA	
PALLET JACK		REFER UNIT		DISPATCHER		CARMICHAEL	
SHIPPING		ROUTE DELIVERY		COMPUTER		DAVIS 	
STOCKING		SNOW/ICE/CHAINING		ROUTING		DIXON	
SCAN GUN		50 LBS-LIFTING		MAP READING		EAST SAC	
COMPUTER		75 LBS-LIFTING		BILINGUAL		EL DORADO HILLS	
ORDER PULLER		100 LBS-LIFTING		CUST. SERVICE		FAIRFIELD	
DOCK WORKER		BOOMLIFT		TYPING		FOLSOM	
DRIVER HELPER		BAY AREA		DATA ENTRY		FRESNO	
						HAYWARD	
MECHANIC				SHIFT/DAYS		LODI	
AIRBREAKS		CLERICAL		1ST SHIFT		MANTECA	
DIESEL		COMMUNICATION		2ND SHIFT		MODESTO	
GAS		FILING CLERK		3RD SHIFT		NEWARK	
BILINGUAL		INTERNET/INTRANET		MONDAY		NORTH HIGHLANDS	
TRAILER REPAIR		CUSTOMER SERVICE		TUESDAY		NORTH SAC	
WELDING		TYPING-BEG		WEDNESDAY		OAKLAND	
MIG WELDING		TYPING-KNOWL		THURSDAY		PATTERSON	
TIG WELDING		TYPING-EXP		FRIDAY		PITTSBURG	
ARK WELDING		PBX/SWITCHBOARD		SATURDAY		RANCHO CORDOVA	
50 LBS-LIFTING		COPIER MACHINE		SUNDAY		ROCKLIN	
75LBS-LIFTING		DATA ENTRY		TEMP 		ROSEVILLE	
100LBS-LIFTING		BILINGUAL		TEMP TO HIRE		SACRAMENTO	
		MS WORD		ON CALL		SOUTH SAC	
MACHINEST		MS EXCEL		DIRECT HIRE		STOCKTON	
METAL		MULTI-LINE PHONES				TRACY	
PLASTIC		RECEPTIONIST				VACAVILLE	
SHEET METAL		GOOD PHONE VOICE				WEST SAC	
BILINGUAL		10 KEY BY SIGHT				WOODLAND	
		10 KEY  BY TOUCH					

Driver skill evaluation sheet

 

Haver ou ever been denied a license, permit or privilege to operate a motor vehicle?	 Yes	 No

Are you familiar with the Federal Motor Carrier (FMC) Safety Regulations?	 Yes	 No

Has any license, permit or privilege ever been suspended or revoked? 	 Yes	 No

Do you know how to maintain a driver’s log?	 Yes	 No

Do you have doubles experience?	 Yes	 No	How much? ________________________________

Do you have harbor experience?	 Yes	 No	How much? ________________________________

Will you unload your own truck?	 Yes	 No	What size trailers have you pulled?______________

Have you ever operated a hostler?	 Yes	 No	Have you ever been road tested?	 Yes	 No

Do you have your own Map Books or GPS?	 Yes	 No	What counties? _____________________________

Can you operate a refrigerated unit (reefer)?	 Yes	 No	Have you ever hauled perishables? 	 Yes	 No

Have you done any line driving or long haul?	 Yes	 No	How much? ________________________________

Have you worked as a team driver?		 Yes	 No 	How much? ________________________________

Long Haul Drivers: Did you have multiple 
stops or drops?	 Yes	 No	How much? _________________________

Local Drivers: How many stops or drops a day did you have? ________________________________________________

What endorsements do you posses? _________________? If Haz-mat, are you familiar with placards?	 Yes	 No

Skill	Experience	Skill	Experience	
 Bus Driver		 Doubles		
 Chauffeur		 Flatbed		
 Hostler		 Hazardous Materials		
 Bobtail – Class B		 Map Books/GPS		
 Dump Truck – Class A		 Perishables		
 Semi – Class A		 Refrigerated Unit (Reefer)		
 Tanker – Class A		 DMV (Clean)		
 Van Driver		 DMV (Minor Violation)		
 Chaining/Strapping		 DMV (Major Violation)		
 Tie Down Ropes		 DMV (Needed)		

__________________________________   ___________________________________   _________________________
	(Applicant Signature)	 (Print Name) 	(Date)

Insert W-4 Here

DRIVER POLICY

 

Employees assigned to driving duties ("drivers") must at all times meet the following criteria:

•	Drivers must have a current, valid driver's license for the state in which the employee performs his or her driving duties; and
•	Drivers must maintain a clean driving record, i.e., must remain insurable under our company's liability insurance policy and maintain a DMV MVR with less than 2 points.
 
Any employee driving a Company vehicle or driving on Company business must observe all safety, traffic, and criminal laws of this state. No driver may consume alcohol or illegal drugs while driving a Company vehicle, while on Company business, while in a Company vehicle, or prior to the employee's shift if such consumption would result in a detectable amount of alcohol or illegal drugs being present in the employee's system while on duty. In addition, no driver may consume or use any substance, regardless of legality or prescription status, if by so doing, the driver's ability to safely operate a motor vehicle and carry out other work-related duties would be impaired or diminished. No driver may pick up or transport non-employees while in a Company vehicle or on Company business, unless there is a work-related need to do so. Any illegal, dangerous, or other conduct while driving that would tend to place the lives or property of others at risk is prohibited.
 
Anything a driver does in connection with the operation of motor vehicles whether in a personal vehicle or company vehicle can affect that driver's fitness for duty or insurability as a driver. Regardless of fault, circumstance, time, or place, any driver who receives a traffic citation from or is arrested by a law enforcement officer, or who is involved in any kind of accident while driving, must inform an appropriate supervisor about the incident immediately or as soon as possible thereafter. Any penalty, fine, imprisonment, fee, or other adverse action imposed by a court in connection with such an incident must be reported immediately to an appropriate supervisor. In both of the above situations, the matter will be reported to the Company's insurance carrier so that a prompt decision on continued coverage of the employee can be made. The driver involved in an accident or cited by a law enforcement official for violating a motor vehicle law must turn over any documentation relating to such incident as soon as possible to the employer, and must cooperate fully with the employer in verifying the information with other parties involved and with law enforcement authorities. While parking tickets will not affect a driver's insurability, any parking ticket issued on a vehicle that is being used for company business should be reported to an appropriate supervisor at the earliest possible opportunity.

Furthermore, any incident or accident caused as a direct or indirect result of driver negligence will be deemed a violation of this driver policy.
 
Any employee who violates any part of this policy, or who becomes uninsurable as a driver, will be subject to reassignment, disciplinary action, or termination from employment. The severity of the discipline is at the discretion of the Company Depending on the nature of the offense, the Company reserves the right to skip any steps at its discretion. All employees with driving duties must sign the following agreement:

I have read and understand the Company's Driver Policy, and I agree, in the event that I am ever involved in an accident, found to be uninsurable, or that I lack a clean driving record or a valid and current driver's license, that if necessary, I will accept whatever alternative assignment the Company may give me and that I understand that a reduction in pay, change in hours, change in duties, and/or change in work location may result from the reassignment. I further understand that the Company does not and cannot guarantee that any particular reassignment will be available in the event of a problem with my driver's license, driving record, or insurability as a driver, and that if no reassignment is possible, termination of my employment will occur.

_______________________________   _______________	_______________________________   _______________
	(Applicant Signature)	(Date)	(Recruiter Signature)	 (Date)

Insert I-9 Here

dot/fmcsa previous employment investigations and inquiries

 

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 Employer Investigation and inquirers on previous employee’s drug and alcohol history.

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 . 
(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)

CERTIFICATE OF COMPLIANCE
WITH CELL-PHONE/TEXTING BANS
Motor carriers: The restrictions in 49 CFR Part 392 on using a mobile telephone or texting while driving apply to every operator of a “commercial motor vehicle” as defined in Section 390.5, including interstate vehicles weighing or rated at 10,001 pounds or more, vehicles placarded for hazardous materials, and certain vehicles designed or used for more than 8 passengers (including the driver). In-state operations of vehicles placarded for hazardous materials are also subject to the restrictions. Other in-state-only operations may also be subject, depending on state rules. 
Drivers: Part 392 of the Federal Motor Carrier safety regulations contains restrictions on texting and the use of hand-held mobile telephones while driving a commercial motor vehicle (CMV), including the following:

1.	Texting ban (392.80): You may not manually enter text into or read text into or read text from an electronic device while driving a CMV. This includes e-mailing, text messaging, using the internet, pressing more than one button to start or end a phone call, or any other form of text retrieval or entry for communication purposes.

2.	Hand-held-cell-phone ban (392.82): You are prohibited from using a hand-held cell phone while driving a CMV. This includes talking on a phone while holding it in your hand (including push-to-talk), pressing more than a single button to dial or answer a cell phone, or leaving your normal, seated driving position to reach for a cell phone.

Except as prohibited under company policy, you are allowed to use a hands-free phone, a CB radio, a navigation system, a two-way radio, a music player, or a fleet management system for purposes other than texting. Texting and hand-held cell-phone use are only allowed if you need to contact emergency services or if you have stopped in a safe location off the road.

Penalties: (383.51, 391.15): CDL and non-CDL drivers can be disqualified for 60 up to 120 days and/or face fines of up to $2750 for each violation.

DRIVER CERTIFICATION: I certify that I have read and understood the above requirements. 

Driver’s Name (Print):_______________________________________Date: ________________

Driver’s Signature:__________________________________________Date:________________

Employer’s Signiture:________________________________________Date:________________