SEI/Aaron s Inc. DOT Regulated Driver Qualification File Checklist. Driver Name: Soc. Sec. # : Facility # :

Transcription

1 SEI/Aaron s Inc DOT Regulated Driver Qualification File Checklist Driver Name: Soc. Sec. # : Facility # : day s Date: Hire Date: Job Title: State: _ Required Documents Notes/Comments Initial when complete 1) Copy of Drivers License (legible) 2) DOT Driver Application 3) Request for Information from Previous Employers (3 years of previous employment) 4) Consent Obtain Consumer Report 5) Medical Examiners Report 6) Medical Certificate with Expiration Date 7) Record of Road Test 8) Certificate of Road Test 9) Motor Vehicle Report 1

2 SEI/Aaron s Inc Driver Application for Employment Instructions Each application form must be completed by the applicant, must be signed by the applicant, and contain the following information The applicant s name, address, date of birth, and social security number The addresses at which the applicant has resided during the three years preceding the date on the application Indicate the date on which the application was submitted The issuing state, number, and expiration date of each unexpired motor vehicle operator s license or permit that has been issued to the applicant Describe the nature and extent of the applicant s experience in the operation of motor vehicles, including the types of motor vehicles that applicant has operated A list of all motor vehicle accidents in which the applicant was involved during the three years preceding the date the application was submitted, specifying the date and nature of each accident and any fatalities or personal injuries it caused A list of all violations of motor vehicle laws or ordinances (other than parking) of which the applicant was convicted or forfeited bond or collateral during the three years preceding the date of the application A statement setting forth in detail the facts and circumstances of any denial, revocation, or suspension of any license, permit, or privilege to operate a motor vehicle that has been issued to the applicant or a statement that no such denial, revocation, or suspension has occurred A list of the names and addresses of the applicant s employers for 3 years preceding the date of application for which the applicant was an operator of a commercial motor vehicle, together with the dates of employment and the reason for leaving such employment The following certification and signature line, which must appear at the end of the application form and be dated and signed by the applicant: 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. 2

3 SEI/Aaron s Inc. For internal use only: Hire Date: Hiring Location: DRIVER S APPLICATION FOR EMPLOYMENT (Please use pen) {Your Company Name Here} is an equal opportunity employer and does not discriminate in any aspect of employment on the basis of race, color, religion, sex, pregnancy, sexual orientation, national origin, marital status, age, ancestry, veteran status, physical or mental disability, or any other legally protected status. Please exclude any information, which may indicate your race, color, religion, sex, pregnancy, sexual orientation, national origin, marital status, ancestry, veteran status, physical or mental disability, or any other legally protected status. Position applied for Date of application Name _ Social Security Number_ Last First Middle (List addresses of residency for the past three years) Current _ Street City How long State Zip Phone Number Previous How long Street City State Zip Previous How long Street City State Zip Previous How long Street City State Zip Date of Birth (required for commercial drivers) Can you provide proof of age? _ Are you now employed? _ If not, how long since leaving last employment? Have you ever been convicted of a felony or misdemeanor other than a minor traffic violation? [ ] YES [ ] NO If yes, please explain (a conviction is not an absolute bar to employment but will be considered as it relates to fitness and ability to perform the job. 1

4 Accident History Accident record for past 3 years or more (attach sheet if additional space is needed). If none, write NONE Dates Nature of accident (Head on, rear-end, upset, etc.) Fatalities Injuries Traffic Convictions and Forfeitures Traffic Convictions and forfeitures for the past 3 years (other than parking violations). If none, write NONE Location Date Charge Penalty (Attach sheet if additional space is needed) License Information Section FMCSR states No person who operates a commercial vehicle shall at any time have more than one driver license. I certify that I do not have more than one motor vehicle license, the information for which is listed below State License Number Type Expiration Date Have you ever been denied a license, permit, or privilege to operate a motor vehicle? [ ]YES [ ]NO Has any license, permit, or privilege ever been suspended or revoked? [ ]YES [ ]NO If the answer to A or B is YES, attach statement-giving details. Class of Equipment Straight truck Tractor and Semi Trailer Tractor two trailers Motorcoach School bus Other Driving Experience (if none, write NONE) Type of Equipment (Van, Dates Tank, Flat, Etc.) Approximate Number of Miles (tal) List States operated in for the last 5 years Show special courses or training that will help you as a driver Which safe driving awards do you hold and from whom? Education Information School Name High School, College, Technical City State Graduated [ ]YES [ ]NO [ ]YES [ ]NO [ ]YES [ ]NO If you did not graduate from high school, did you complete the G.E.D.? [ ] YES [ ] No [ ]YES [ ]NO 2

5 Employment History All driver applicants must provide the following information on all employers and periods of unemployment during the preceding three years. List complete mailing address, street number, city, state, and zip code. List employers in reverse order starting with the most recent. Add another sheet as necessary. Were you subject to the FMCSR s* while employed by this employer? Were you subject to the FMCSR s* while employed by this employer? Were you subject to the FMCSR s* while employed by this employer? Were you subject to the FMCSR s* while employed by this employer? *FMCSR Federal Motor Carrier Safety Regulations 3

6 Employment History Continued All driver applicants must provide the following information on all employers and periods of unemployment during the preceding three years. List complete mailing address, street number, city, state, and zip code. List employers in reverse order starting with the most recent. Add another sheet as necessary. Were you subject to the FMCSR s* while employed by this employer? Were you subject to the FMCSR s* while employed by this employer? Were you subject to the FMCSR s* while employed by this employer? Were you subject to the FMCSR s* while employed by this employer? *FMCSR Federal Motor Carrier Safety Regulations 4

7 Experience and Qualifications Other Show any trucking, transportation, or other experience that may help in your work for this company: List education, training courses and prior military other than those shown elsewhere in this application: List special equipment or technical materials you can work with (other than those already shown): TO BE READ AND SIGNED BY APPLICANT Please read this section. 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 I understand and agree that {Your Company Name} or its authorized representative may verify all information furnished in this application. I waive any right I may have to be notified by any individuals and organizations named in this application prior to the release of any information to {Your Company Name}. I further authorize all individuals and organizations named in this application to give {Your Company Name} all information relative to such verification. I hereby release such individuals and organizations and {Your Company Name} from any and all liability for any claim or damage resulting therefrom. I understand that {Your Company Name} is not obligated to provide employment and that I am not obligated to accept employment. Nothing in this application, or in any prior or subsequent oral or written statement, is intended to create any contract of employment or to create any rights in the nature of a contract of employment. This application does not bind either party for a specific period of time regarding employment. If hired, nothing in this application shall restrict my right as an employee or {Your Company Name} right as an employer to terminate my employment at any time. Signature (sign, do not print) Date 5

8 SEI/Aaron s Inc. Request for Information from Drivers Previous Employer The below named applicant is being considered for employment with {Your Company Name} and has listed your organization as a former employer. Per , / and of the Federal Motor Carrier Safety Regulations, potential employers must obtain verification and previous employers must furnish information on employment, drug and alcohol testing results, and vehicle accidents from the previous three years. This information must be obtained within 30 days of a safety-sensitive function performed by the driver. Please furnish this information within the regulated time frame. Information provided will be treated in confidence. Applicant Name Social Security # Previous Employer Telephone # Fax # City Applicant Signature State / Zip Date Record of Employment ( be completed by previous employer) Position held: Dates employed: (/) (/) What type of equipment driven: Tractor/trailer_ Straight Truck_Doubles_Other_ Accident information: A list of all accidents as defined in of the FMCSR (Until May 1, 2006, carriers need only provide information for accidents that occurred after April 29, 2003) Date of accident/s: (Use back of form to supply information for multiple accidents) City or town, or most near, where accident occurred and the State: Number of injuries: Number of fatalities: Were hazardous materials, other than fuel spill from the fuel tanks of motor vehicle involved in the accident, released? Furnish copies of all accident reports required by State or other governmental entities or insurers Has this person ever tested positive for drugs or alcohol? [ ]YES [ ] NO Has this person ever refused to submit to a drug or alcohol test? [ ]YES [ ] NO Has this person ever had an alcohol test with a Breath Alcohol Concentration? of 0.04 or greater in the past two years? [ ]YES [ ] NO Has applicant violated any other DOT agency s drug and alcohol regulations? [ ]YES [ ] NO Have you received information from a previous employer that this applicant Violated any DOT drug and alcohol regulations? [ ]YES [ ] NO If you answered YES to any of the above drug and alcohol questions, please provide the name and phone number of the contact that can confirm test dates and results_ your knowledge, was this driver s license suspended while in your employ? _If so, explain Printed name and title of person supplying information / Signature of person supplying information_ Title_ Date_/_/_ 1

9 SEI/Aaron s Inc. Request for Information from Drivers Previous Employer The below named applicant is being considered for employment with {Your Company Name} and has listed your organization as a former employer. Per , / and of the Federal Motor Carrier Safety Regulations, potential employers must obtain verification and previous employers must furnish information on employment, drug and alcohol testing results, and vehicle accidents from the previous three years. This information must be obtained within 30 days of a safety-sensitive function performed by the driver. Please furnish this information within the regulated time frame. Information provided will be treated in confidence. Applicant Name Social Security # Previous Employer Telephone # Fax # City Applicant Signature State / Zip Date Record of Employment ( be completed by previous employer) Position held: Dates employed: (/) (/) What type of equipment driven: Tractor/trailer_ Straight Truck_Doubles_Other_ Accident information: A list of all accidents as defined in of the FMCSR (Until May 1, 2006, carriers need only provide information for accidents that occurred after April 29, 2003) Date of accident/s: (Use back of form to supply information for multiple accidents) City or town, or most near, where accident occurred and the State: Number of injuries: Number of fatalities: Were hazardous materials, other than fuel spill from the fuel tanks of motor vehicle involved in the accident, released? Furnish copies of all accident reports required by State or other governmental entities or insurers Has this person ever tested positive for drugs or alcohol? [ ]YES [ ] NO Has this person ever refused to submit to a drug or alcohol test? [ ]YES [ ] NO Has this person ever had an alcohol test with a Breath Alcohol Concentration? of 0.04 or greater in the past two years? [ ]YES [ ] NO Has applicant violated any other DOT agency s drug and alcohol regulations? [ ]YES [ ] NO Have you received information from a previous employer that this applicant Violated any DOT drug and alcohol regulations? [ ]YES [ ] NO If you answered YES to any of the above drug and alcohol questions, please provide the name and phone number of the contact that can confirm test dates and results_ your knowledge, was this driver s license suspended while in your employ? _If so, explain Printed name and title of person supplying information / Signature of person supplying information_ Title_ Date_/_/_ 1

10 SEI/Aaron s Inc. Request for Information from Drivers Previous Employer The below named applicant is being considered for employment with {Your Company Name} and has listed your organization as a former employer. Per , / and of the Federal Motor Carrier Safety Regulations, potential employers must obtain verification and previous employers must furnish information on employment, drug and alcohol testing results, and vehicle accidents from the previous three years. This information must be obtained within 30 days of a safety-sensitive function performed by the driver. Please furnish this information within the regulated time frame. Information provided will be treated in confidence. Applicant Name Social Security # Previous Employer Telephone # Fax # City Applicant Signature State / Zip Date Record of Employment ( be completed by previous employer) Position held: Dates employed: (/) (/) What type of equipment driven: Tractor/trailer_ Straight Truck_Doubles_Other_ Accident information: A list of all accidents as defined in of the FMCSR (Until May 1, 2006, carriers need only provide information for accidents that occurred after April 29, 2003) Date of accident/s: (Use back of form to supply information for multiple accidents) City or town, or most near, where accident occurred and the State: Number of injuries: Number of fatalities: Were hazardous materials, other than fuel spill from the fuel tanks of motor vehicle involved in the accident, released? Furnish copies of all accident reports required by State or other governmental entities or insurers Has this person ever tested positive for drugs or alcohol? [ ]YES [ ] NO Has this person ever refused to submit to a drug or alcohol test? [ ]YES [ ] NO Has this person ever had an alcohol test with a Breath Alcohol Concentration? of 0.04 or greater in the past two years? [ ]YES [ ] NO Has applicant violated any other DOT agency s drug and alcohol regulations? [ ]YES [ ] NO Have you received information from a previous employer that this applicant Violated any DOT drug and alcohol regulations? [ ]YES [ ] NO If you answered YES to any of the above drug and alcohol questions, please provide the name and phone number of the contact that can confirm test dates and results_ your knowledge, was this driver s license suspended while in your employ? _If so, explain Printed name and title of person supplying information / Signature of person supplying information_ Title_ Date_/_/_ 1

11 RECORD OF ROAD TEST Instructions to examiner: Mark "S" all items the driver performs satisfactorily; use "U" where performance is unsatisfactory. Any item not evaluated, mark as N/A. Note remarks in Remarks section Driver's Name Home SSN License # State Class Equipment Driven (truck / tractor) _Trailer(s) (Make and model) (Body type & length) Length of Test _ miles from / in to Start Time _ Finish Time _ Weather Conditions PART 1 - PRE-TRIP INSPECTION AND EMERGENCY EQUIPMENT Checks general condition approaching unit Checks fuel, oil, water and for excessive oil on engine Tests steering, brake assist, tractor protection valve and parking brake Reviews and signs previous report Checks instruments for normal readings Checks dashboard warning lights for proper functioning Cleans windshield, windows, mirrors, lights and reflectors Checks horn, windshield wipers, mirrors, emergency equipment, reflectors, flares, fuses, tire chains (if necessary), fire equipment PART 2 - COUPLING AND UNCOUPLING Couples without difficulty Connects glad hands to trailer to apply trailer brakes before coupling Raises landing gear fully after coupling Visually checks king pin assembly to be certain of proper coupling Connects glad hands and light line properly Assures that surface will support trailer before uncoupling Checks coupling by applying hand valve (trailer air supply valve) and gently applying pressure by trying to pull away from trailer PART 3 - PLACING VEHICLES IN MOTION AND USE OF CONTROLS A. MOTOR B. BRAKES Place transmission in neutral before starting Engine Starts engine without difficulty Checks instruments at regular intervals Maintains proper engine rpm while driving Knows proper use of and checks tractor protection valve (trailer air supply valve) Tests service brakes Builds full air pressure before moving C. CLUTCH AND TRANSMISSION D. LIGHTS (if tested at night) Starts unit moving smoothly Uses clutch properly Adjusts speed for range of headlights Dims Lights when approaching another vehicle or following other traffic 2

12 PART 4 - BACKING AND PARKING A. BACKING B. PARKING (CITY) Gets out and checks area before backing Understands and utilizes mirrors properly Signals when backing from blind side Avoids backing from blind side C. PARKING (ROAD) Parks off pavement Secures unit properly Uses emergency warning signal or device when necessary Parks without hitting any other vehicles or stationary objects Parks correct distance from curb Secures unit properly - sets parking brakes transmission in correct gear, shuts off engine, blocks wheels (when necessary) Carefully enters traffic from parked position PART 5 - SLOWING AND STOPPING Uses clutch and gears properly Gears down properly before descending hills Starts without rolling back Tests brakes before descending grades Uses brakes properly on grades Makes proper use of mirrors Plans stop far enough in advance to avoid hard braking Stops clear of crosswalks PART 6 - OPERATING IN TRAFFIC< PASSING AND TURNING A. TURNING Signals intention to turn well in advance Gets into proper lane well in advance of turn Checks traffic conditions and turns only when intersection is clear Restricts traffic from passing on right when preparing to complete right hand turn Completes turn promptly and safely and does not impede other traffic B. TRAFFIC SIGNS AND SIGNALS Plans stop in advance and adjusts speed correctly Obeys all traffic signals Comes to complete stop at all stop signals C. INTERSECTIONS Yields right of way Checks for cross traffic regardless of traffic controls Enters all intersections prepared to stop if necessary D. GRADE CROSSING Stops at a minimum 15 feet but no more than 50 feet before crossing if stop is necessary Selects proper gear and does not shift gears while crossing Knows and understands federal and state rules governing grade crossings E. PASSING Allows sufficient space ahead for passing Passes only in safe locations Signals changing lanes before and after passing Warns driver ahead of intention to pass Passes with sufficient speed differential to minimize obstructing traffic Returns to right lane promptly but only when safe to do so F. SPEED Observes speed limits Drives at speed consistent with ability Adjusts speed properly to road, weather and traffic conditions Slows down in advance of curves, danger zones and intersections Maintains constant speed where possible 3

13 G. COURTESY AND SAFETY Yields right of way Consistently strives to drive in a safe manner Allows faster traffic to pass Uses horn only when necessary PART 7 - MISCELLANEOUS A. GENERAL DRIVING ABILITY AND HABITS Consistently alert and attentive Consistently is aware of changing traffic conditions Anticipates problems Performs routine functions without taking eyes from the road Checks instruments regularly while driving Personal appearance is professional Remains calm under pressure B. USE OF SPECIAL EQUIPMENT (SPECIFY) REMARKS: GENERAL PERFORMANCE Satisfactory Needs Training Explanation: QUALIFIED FOR: Straight Truck Tractor/Semi-trailer Twin Trailers Other Combination Other (specify) Special Equipment: Examiner's name - PRINT _ Examiners Signature Date Driver s Signature Date 4

14 CERTIFICATION OF ROAD TEST (Note: The Record of Road Test is used as a source document to complete this section and will be attached to this certification upon completion.) If the road test is successfully completed, the person who gave it must ensure that the original of this certification is sent to human resources to be placed in the person s file and a duplicate copy of this road test certification is provided to the person examined. ( (e) (f)(g)(1)(2) Federal Motor Carrier Regulations) Driver s Name SSN Operator s or Chauffeur s License No. State Type of Power Unit Type of Trailer This is to certify the above named driver was given a road test under my supervision on _/ /_ (Date) Consisting of approximately miles of driving. It is my considered opinion this driver possesses sufficient driving skill to operate the type of commercial vehicle listed above. Signature of Examiner Title Company of Examiner Driver s Signature Date 5

15 CERTIFICATION OF ROAD TEST Drivers Name Operator's or Chauffeur's License No. State Type of Power Unit _ 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 possesses sufficient driving skill to operate safely the type of commercial motor vehicle listed above Signature of examiner Title Organization and address of examiner 6