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Employment    
DRIVER APPLICANT DRUG AND ALCOHOL  
PRE-EMPLOYMENT STATEMENT  
     
MUST BE COMPLETED PRIOR TO COMPLETING APPLICATION  
CFR Part 40.25 (j) requires the employer to ask any applicant, whether he or she has tested positive, or refused to test, on any pre-employment drug or alcohol test administered by an employer to which the employee applied for, but did not obtain, safety-sensitive transportation work covered by DOT agency drug and alcohol rules during the past two years. If the potential employee admits that he or she had a positive test or refusal to test, you must not use the employee to perform safety-sensitive function, until and unless, the potential employee provides documentation of successful completion of the return-to-duty process. See Section 40.25 (b) (5) and (e).
Applicant Name  
As an applicant, applying to perform safety-sensitive functions for our company, you are required by CFR Part 40.25 (j) to respond to the following questions.
Birthdate (MM/DD/YYYY)  
Social Security Number  
1. Have you tested positive, or refused to test, on any pre-employment drug or alcohol test administered by an employer to which you applied for, but did not obtain, safety-sensitive transportation work covered by DOT agency drug and alcohol testing rules during the past two years?
 
2. If you answered yes, to the above question, can you provide proof that you've successfully completed the DOT return-to-duty requirements?
 
By checking this box, I certify that the information provided above is true and correct.
DRIVERS RIGHTS PERTAINING TO RELEASE OF DRIVER INFORMATION UNDER REGULATION 391.23

Motor carriers have the responsibility to make the following investigations and inquiries with respect to each driver employed, other than a person who has been a regularly employed driver of the motor carrier for a continuous period which began before January 1, 1971.

 
  • (a)(1)
An inquiry into the driver's driving record during the preceeding three years to the appropriate agency of every State in which the driver held a motor vehicle operator's license or permit during those three years; and  
 
  • (a)(2)
    		•  An investigation of the driver's employment record during the preceding three years.  
     
  • (b)
    		•  A copy of the driver record(s) obtained in response to the inquiry or inquiries to each State driver record agency as required must be placed in the Driver Qualification File within 30 days of the date the driver's employment begins and be retained in compliance with 391.51.  
     
  • (c)
    		•  Replies to the investigations of the driver's safety performance history must be placed in the Driver Investigation History File within 30 days of the date the driver's employment begins. This goes into effect after October 29, 2004.  
     
  • (d)
    		•  Prospective motor carrier must investigate the information from all previous employers of the applicant that employed the driver to operate a CMV within the previous three years. This information must cover general driver identification and employment verification information, data elements as specified in 390.15 for accident involving the driver that occurred in the three-year period preceding the date of the employment application, and any accidents the previous employer may wish to provide.  
     
  • (e)
    		• Propective motor carrier must investigate the information from all previous DOT regulated employers that employed the driver within the previous three years from the date of the employment application in a safety-sensitive function that required alcohol and controlled substance testing specified by 40CFR Part 40.  

    Drivers have the following rights:

     
    1. The right to review information provided by previous employers.

    2. The right to have errors in the information corrected by the previous employer and for that previous employer to re-send the corrected information to the prospective employer.

    3. The right to have a rebuttal statement attached to the alleged erroneous information, if the previous employer and driver cannot agree on the accuracy of the information.

    Drivers who wish to review previous employers-provided investigative information must submit a written request to the prospective employer when applying or as late as 30 days after emplyed or being notified of denial of employment. The prospective employer must provide this information to the applicant within five business days of receiving the written request. If the driver has not arranged to pick up or receive the rerquested records within 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.

    Drivers wishing to request correction of erroneous information in records must send the request for the correction to the previous employer that provided the records. 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 the driver's request to correct the data that it does not agree to the correct the data. Drivers wishing to rebut information in records must send the rebuttal in the driver's Safety Performance History.

    By checking this box, I acknowledge that I have read and understand the contents of this document.

    A&W Water Service, Inc.
    1892 Denver Avenue
    Fort Lupton, Colorado 80621
    The purpose of this application is to determine whether or not the applicant is qualified to operate motor carrier equipment according to the requirements of the Federal Motor Carrier Safety Regulations and the Company named above.

    Instructions to Applicant
    Please answer all questions. Do not leave any items blank.

    Position applying for:  
    First Name  
    Middle Name  
    Last Name  
    Phone Number  
    Emergency Phone Number  
    Age*

    		  
    Physical Exam Expiration Date  
    Current and Three Years Previous Addresses:
     
     
    Have you worked for this company before?  
    If yes, give dates:  
    Reason for Leaving?  
    Education History  
    Please select the highest grade completed:  
    Grade School  
    College  
    Post-Graduate  
    Employment History  
    Give a Complete Record of all employment for the past three years, including any unemployment or self employment, and all commerical driving experience for the past ten years.
     
     
     
    Were you subject to the FMCSRs* while employed here?  
    Was your job designated as a safety-sensitive function in any DOT-Regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40?
     
     
     
    Were you subject to the FMCSRs* while employed here?  
    Was your job designated as a safety-sensitive function in any DOT-Regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40?
     
     
     
    Were you subject to the FMCSRs* while employed here?  
    Was your job designated as a safety-sensitive function in any DOT-Regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40?
     
     
     
    Were you subject to the FMCSRs* while employed here?  
    Was your job designated as a safety-sensitive function in any DOT-Regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40?
     
     
     
    Were you subject to the FMCSRs* while employed here?  
    Was your job designated as a safety-sensitive function in any DOT-Regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40?
    *The Federal Motor Carrier Safety Regulations (FMCSRs) apply to anyone who operates a motor vehicle on a highway to interstate commerce to transport passenders or property when the vehicle: (1) has a GVWR or weighs 10,001 pounds or more. (2) is designed or used to transport nine or more passengers. or (3) is of any size, used to transport hazardous materials in a quantity requiring placarding.
    Driving Experience  
    Class of Equipment From Date To Date Approximate Number of Miles (Total)
    Straight Truck
    Tractor and Semi-trailer
    Tractor-two trailers
    Tractor-three trailers (triples)
    Other
    List states operated in, for the last five years:
    List special courses/training completed (PTD/DDC, Haz Mat, Etc.):
    List any Safe Driving Awards you hold and from whom:
    Accident Record for the past three years
    Date of Accident
    Nature of Accidents
    (Head on, Rear end, Upset, etc)
    Location of Accident
    # of Fatalities
    # of People Injured
    Traffic Convictions and Forfeitures for the last three years (other than parking violations)
    Date
    Location
    Charge
    Penalty
    Driver's License (list each drivers license held in the past three years)
    State
    License Number
    Type
    Endorsements
    Expiration Date
    A. Have you ever been denied a license, permit or privilege to operate a motor vehicle?
    B. Has a license, permit or privilege ever been suspended or revoked?
    C. Is there any reason you might be unable to perform the functions of the job for which you have applied (as described in the job description)?
    D. Have you ever been convicted of a felony?
    If the answers to A, B, C, or D is "YES", give details
    Personal References  
    List three persons for references, other than family members, who have knowledge of your safety habits.

    It is agreed and understood that any misrepresentation given on this application shall be considered an act of dishonesty. It is agreed and understood that the motor carrier or his agents may investigate the applicant's background to ascertain any and all information of concern to applicant's record, where same is of record or not, and applicant releases employers and persons named herein from all liability for any damages on account of his furnishing such information. It is also agrred and understood that under the fair credit Reporting Act, Public Law 91-508, I have been told that this investigation may include and investigationg Consumer Report, including information regarding my character, general reputation, personal characteristics, and mode of living. I agree to furnish such additional information and complete such examinations as may be required to complete my application file. It is agreed and understood that this Application for Qualification in no way obligates the motor carrier to employ or hire the applicant. It is agreed and understood that if qualified and hired, I may be on a probationary period during which time I may be disqualified without recourse. This certifies that this application was completed by me, and that all entries on it and information in it are true and complete to the best of my knowledge.

    By checking this box I agree with the above statement.

    Copyright 2011
    A&W Water Service, Inc. - A Complete Energy Services Company
    All Rights Reserved