Driver Employment Application

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1 Driver Employment Application Diaz Road Temecula, CA (951) / Fax: (951) US DOT# Table of Contents An Equal Opportunity Employer Driver Qualification & Acceptable Driver Criteria... 2 Applicant Information... 3 Driver License Information... 3 Employment Desired... 3 Driver Experience... 4 Tickets & Accidents Information... 4 Employment Record Declaration of Conviction Information... 7 Declaration of Employment Status... 7 Equal Employment Opportunity Data... 8 Disclosure and Acknowledgement of Intent to Obtain Information... 9 Alcohol and Controlled Substance Consent and Release Disclosure Disclosure and Authorization to Obtain Information DOT Requirements Certification of Compliance with Driver License Annual Review of Driving Record Safety Performance History Records Request Driver Road Test Examination Certification of Road Test Before you begin... Applicants must complete pages 3 17 in full: All pages that provide a space for a signature must be signed and dated. All pages must be turned in when submitting your application. Page 7: is intended to provide notice to the applicant that Southwest Traders, Inc. will perform a background check as this is required to be considered for employment. All applicants must sign and date all required fields on this page. Page 11: must be completed in order to consider your application for employment. Pages 16 17: is the Drivers Road Test Examination and is mandatory for all CDL drivers. Southwest Traders will complete this document when evaluating the driver's performance. Please retain this page for your records. 1

2 DRIVER QUALIFICATION REQUIREMENTS PLEASE READ AND APPLY ONLY IF YOU MEET THE FOLLOWING REQUIREMENTS The Federal Regulations set forth minimum standards for drivers of all vehicles over 10,000 lbs. GVW or GVWR operating in interstate commerce. The driver must demonstrate that he / She: Minimum Federal Requirements Is 21 years of age Can Sufficiently Speak the English Language Can safely operate the type of equipment he/she will be assigned to drive Has a valid license to operate a commercial motor vehicle Has provided Southwest Traders with a list of moving violations for the past three years Is not disqualified to be a driver Has a road test certificate or equivalent (Provided by SWT s) Experience Requirements for Employment with Southwest Traders, Inc. Has a minimum of 2 years of recent experience driving equipment similar to that used by SWT s At least 1 year of recent route delivery experience preferred 2 years customer service experience with strong communication skills Capable of lifting, pushing and/or pulling up to 80 lbs. and know how to use a pallet jack and 2 wheel cart Must pass pre employment drug test Current Class A driver license Must meet the Acceptable Driver Criteria as outlined below General Conviction Guidelines for All Southwest Traders Employee s Conviction of a Felony as an adult. Conviction of any crime, while an adult, involving a child, the elderly and/or a dependant adult. Conviction of any violent crime within the 10 years preceding the individual s application. Conviction of any crime of theft, burglary, embezzlement, larceny or any other crime for monetary gain. Conviction of any crime as set forth above, while an employee. Conviction for any other crime deemed by Southwest Traders, Inc. as disqualifying. No felony convictions or confinement for conviction of a criminal offense (regardless of severity) in the past 7 years ACCEPTABLE DRIVER CRITERIA NON ACCEPTABLE DRIVING RECORD: One or more Major convictions within the last Five Years; or One Accident (with points assigned) and Two minor convictions within the last Two Years; or Two minor convictions within One Year; or Three minor convictions within Two Years; or Two accidents (with points assigned) in the last Three Years. Major Convictions as defined as but not limited to: 1. Driving under influence of drugs/alcohol (DUI) 2. Failure to stop/report an accident (Hit and Run) 3. Reckless driving/speed contest 4. Driving while impaired 5. Making a false accident report 6. Careless driving 7. Attempting to elude a Peace Officer 8. Driving in excess of 100 miles per hour 9. Any motor vehicle Felony 10. Homicide, manslaughter or assault rising out of use of vehicle Minor Convictions as defined is any moving violation other than a major EXCEPT: 1. Motor vehicle equipment, load or size requirement 2. Improper/failure to display license plates 3. Failure to sign or display registration 4. Failure to have drivers license in possession Years are based on Conviction Date not Calendar Date 1. Minor convictions remain on record; Three Years and One Month 2. Major convictions remain on record; Seven Years and One Month 3. DUI convictions remain on record; Ten Years and One Month Please retain this page for your records. 2

3 APPLICANT CONTACT INFORMATION First Name: Middle Initial: Last Name: Application # Home Phone: Cell Phone: Social Security #: E Mail Address: Date Applied: Mailing Address: Apt. #: City: State: Zip Code: How Long: IF LESS THEN THREE YEARS AT CURRENT RESIDENCE, PROVIDE PREVIOUS ADDRESS Address: Apt #: City: State Zip Code: How Long: DRIVER LICENSE INFORMATION Driver License #: State: Class: Expiration: EMPLOYMENT DESIRED Position Applying For: How Did You Hear About The Position: Internet Site Walk In Friend Family Member Are You Applying For: Full Time: Part Time: Temporary: When are you available for Work: Week Days: Nights: Weekends: Any: Are You Available To Work Overtime If Necessary: Yes: No: If Hired, On What Date Would You Be Able To Start Work: Salary Desired: 3

4 DRIVER EXPERIENCE (49 CFR ) Class of Equipment: Straight Truck Tractor & Semi Trailer Tractor Two Trailers Other: Type Of Equipment: Date From: Date To: Approx. # Of Miles: Class of Equipment: Straight Truck Tractor & Semi Trailer Tractor Two Trailers Other: Type Of Equipment: Date From: Date To: Approx. # Of Miles: 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 Have you ever been convicted of any criminal act involving the use of a Commercial Motor Vehicle or while driving a commercial motor vehicle? Yes NO If you answered yes to any of the above 3 questions, provide a statement of explanation below (If more space is required, please attach an additional sheet of paper to the back of this application with the necessary information) TICKETS / ACCIDENTS / ETC. Date: Description: Number of injuries / Fatalities: Date: Description: Number of Injuries / Fatalities: Date: Description Number of Injuries / Fatalities: Traffic Conviction & Forfeitures For Past 3 Years Date: Location: Charge or Penalty: Date: Location: Charge or Penalty: Date: Location: Charge or Penalty: 4

5 HISTORY WITH COMPANY WHICH YOU ARE APPLYING Have you worked for this company before? Yes No (if yes, please indicate dates below) EMPLOYMENT RECORD (NOTE: DOT requires employment for 3 years previous and/or commercial driving experience for past 10 years be shown.) Employer: Employed From: To: Address: Phone: ( ) Supervisor: Position: Reason for Leaving: Job Duties: Were you subject to the FMCSRs while employed? Yes No Was your job designated as a safety sensitive function in any DOT regulated mode subject to the drug & alcohol testing requirements of 49 CFR Part 40? Yes No Employer: Employed From: To: Address: Phone: ( ) Supervisor: Position: Reason for Leaving: Job Duties: Were you subject to the FMCSRs while employed? Yes No Was your job designated as a safety sensitive function in any DOT regulated mode subject to the drug & alcohol testing requirements of 49 CFR Part 40? Yes No Employer: Employed From: To: Address: Phone: ( ) Supervisor: Position: Reason for Leaving: Job Duties: Were you subject to the FMCSRs while employed? Yes No Was your job designated as a safety sensitive function in any DOT regulated mode subject to the drug & alcohol testing requirements of 49 CFR Part 40? Yes No Employer: Employed From: To: Address: Phone: ( ) Supervisor: Position: Reason for Leaving: Job Duties: Were you subject to the FMCSRs while employed? Yes No Was your job designated as a safety sensitive function in any DOT regulated mode subject to the drug & alcohol testing requirements of 49 CFR Part 40? Yes No 5

6 EMPLOYMENT RECORD CONTINUED (If additional space is required, please attach another sheet of paper to the back of this application) Employer: Employed From: To: Address: Phone: ( ) Supervisor: Position: Reason for Leaving: Job Duties: Were you subject to the FMCSRs while employed? Yes No Was your job designated as a safety sensitive function in any DOT regulated mode subject to the drug & alcohol testing requirements of 49 CFR Part 40? Yes No Employer: Employed From: To: Address: Phone: ( ) Supervisor: Position: Reason for Leaving: Job Duties: Were you subject to the FMCSRs while employed? Yes No Was your job designated as a safety sensitive function in any DOT regulated mode subject to the drug & alcohol testing requirements of 49 CFR Part 40? Yes No Employer: Employed From: To: Address: Phone: ( ) Supervisor: Position: Reason for Leaving: Job Duties: Were you subject to the FMCSRs while employed? Yes No Was your job designated as a safety sensitive function in any DOT regulated mode subject to the drug & alcohol testing requirements of 49 CFR Part 40? Yes No Employer: Employed From: To: Address: Phone: ( ) Supervisor: Position: Reason for Leaving: Job Duties: Were you subject to the FMCSRs while employed? Yes No Was your job designated as a safety sensitive function in any DOT regulated mode subject to the drug & alcohol testing requirements of 49 CFR Part 40? Yes No 6

7 DECLARATION OF CONVICTION INFORMATION No applicant will be denied employment solely on the grounds of a conviction of a criminal offense. The nature of the offense, the date of the offense, the surrounding circumstances and the relevance of the offense to the position(s) applied for may however, be considered. Have you ever been convicted of a criminal offense Felony? Misdemeanor? Both? None. (Convictions for Marijuana related offenses that are more than 2 years old need not be listed) If you have been convicted of a crime(s), please answer the following questions: Date of Conviction: Location of Conviction: Disposition of the Case: DECLARATION OF EMPLOYMENT STATUS (This refers to any gaps in employment history) I understand that I must provide my complete employment history for the past 3 years, and all CDL required employment for the 7 years preceding that. Any gaps in employment longer than 1 month are explained as follows: DATES FROM: TO: During this time I was engaged in the following activity: In addition I was not employed by any company or individual during this time (Please Initial): To Be Read and Signed By Applicant I authorize you to make such investigations and inquiries of my personal, employment, financial or medical history and other related matters as may be necessary in arriving at an employment decision. (Generally inquiries regarding medical history will be made only if and after a conditional offer of employment has been extended.) I hereby release employers, schools, health care providers and other persons from all liability in responding to inquiries and releasing information in connection with my application. In the event of employment, I understand that false or misleading information given in my application or interviews may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the Company. I understand information I provide regarding current and/or previous employers may be used, and those employers will be contacted, for the purpose of investigating my safety performance history as required by 49 CFR (d) and (e). I understand that I have the right to: Review information provided by the previous employers; Have errors in the information corrected by previous employers and for those previous employers to re send the corrected information to the prospective employer; and Have a rebuttal statement attached to the alleged erroneous information, if the previous employer(s) and I cannot agree on the accuracy of the information. This certifies 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. Applicant Signature: Date: 7

8 EQUAL EMPLOYMENT OPPORTUNITY DATA TO BE COMPLETED BY APPLICANT APPLICATION DATE: Completion of this form is entirely voluntary, and all information will remain confidential and will not affect your application for employment. We are required by law to collect this information for equal opportunity employment purposes, and it will not become part of your personnel record if you are hired by this company. Name: Sex: Male: Female: Race / Ethnicity: American Indian or Alaskan Native Asian Black or African American Hispanic or Latino White Native Hawaiian or other Pacific Islander Two or more races Government contractors must take affirmative action to employ and advance certain qualified individuals subject to the Rehabilitation Act of 1973 and the Vietnam Era Veterans Readjustment Act of Completion of the following information is voluntary, and will assist us in proper placement and reasonable accommodation. If you wish to be identified as qualifying for such placement or accommodation, please check where applicable: Vietnam Era Veteran Disabled Veteran Individual with a Disability TO BE COMPLETED BY EMPLOYER: EEO 1 Category: 1a. Executive / Senior Level Officials and Managers 1b. First / Mid Senior Level Officials and Managers 2. Professionals 3. Technicians 4. Sales 5. Administrative Support Workers 6. Craft Workers 7. Operatives Semi Skilled 8. Laborers and Helpers 9. Service Workers Employer Information Completed By Name: Date: 8

9 INSIGHT INVESTIGATIONS, INC DISCLOSURE AND ACKNOWLEGEMENT OF INTENT TO OBTAIN INFORMATION I understand that as a condition for consideration of employment with Southwest Traders, Inc ( Company ), I will authorize Company to conduct a consumer and/or investigative consumer report on me for employment purposes from INSIGHT INVESTIGATIONS, INC. Such reports may include, but are not limited to, information as to my character, general reputation, personal characteristics, and mode of living; discerned through employment and education verifications; personal references and interviews; my personal credit history based on reports from any credit bureau; my driving history, including any traffic citations; workers' compensation records after a conditional job offer has been extended and to the extent permitted by law; a social security number trace; present and former addresses; criminal and civil history/records; and any other public record. Additionally, I will authorize any person, business entity or governmental agency that may have information relevant to the above to disclose the same to Company and Insight Investigations, Inc. including, but not limited to, any and all courts, public agencies, law enforcement agencies and credit bureaus. I authorize Company to share such information only with parties in interest who have a "need to know" of such information to protect them and their employees. Insight Investigations, Inc. does not sell or otherwise provide any of the information found in its background investigations to any party other than the Company. The above stated disclosure is step one in the application process with Southwest Traders, Inc. By signing below, you agree to these terms and understand that this does not constitute an offer for employment. Should you be given further consideration and after a formal interview has been conducted, you may be asked to complete the full disclosure and the consumer and/or investigative consumer report will be requested from Insight Investigations, Inc. Pending the outcome of the report combined with the information gathered from your application and your interview with a Company representative, you may at that time be offered employment with Southwest Traders, Inc. Print Name: Date: Signature: 9

10 ALCOHOL AND CONTROLLED SUBSTANCE CONSENT AND RELEASE DISCLOSURE Have you ever refused to be tested for drugs & alcohol? Yes No Have you ever tested positive for drugs or alcohol? Yes No Have you ever tested positive on any pre employment drug or alcohol test for a job which you applied for but did not obtain? Yes No (If you answered yes to any of the above questions, attach a statement of explanation and provide proof of return to duty process) I understand that, as required by the Federal Motor Carrier Safety Regulations and company policy, all drivers must submit to alcohol and controlled substance testing as a condition of employment. I also understand that any offer of employment will be contingent upon the results of an alcohol and controlled substance test. Therefore, I agree to submit to the following alcohol and controlled substance tests in accordance and as defined by the Federal Motor Carrier Safety Regulation and this company's policies: Pre Employment, to determine employment eligibility Random Reasonable Suspicion Post Accident Follow Up (see company policy) Return to duty (see company policy) I certify that I have read, understand, and agree to abide by the condition of this consent and release form. Signature: Date: Print Name: Social Security # Employer Witness: Company Name: Southwest Traders, Inc. **THE FOLLOWING PAGE #11 MUST BE COMPLETED WHEN SUBMITTING YOUR APPLICATION OR IT WILL NOT BE ACCETPTED** 10

11 CONSENT TO OBTAIN CONSUMER REPORTS FOR EMPLOYMENT PURPOSES In connection with, and for the duration of, my employment (including contract for services) with you, I understand that you may obtain consumer reports for employment purposes that relate to my credit, criminal, driving, employment or education history. This information will, in whole or in part, be obtained from Insight Investigations, Inc. ( Insight ) PO Box , Temecula, CA (800) These reports may include information as to my general reputation, character, personal characteristics, mode of living, work habits, job performance and experience along with reasons for termination of past employment from pervious employers. I understand that you may be requesting information from various federal, state and other agencies or institutions, which maintain public and non-public records concerning my past activities relating to my driving, credit, civil, education and other experiences. I authorize, without reservation, any party, institution, or agency contacted by Insight or this employer to furnish the above mentioned information: Notice to CALIFORNIA Applicants Under Section of the California Civil Code, you have the right to request from Insight, upon proper identification, the nature and substance of all information in its files on you, including the sources of information, and the recipients of any reports on you, which Insight has previously furnished within the two-year period preceding your request. You may view the file maintained on you by Insight during normal business hours. You may also obtain a copy of this file upon submitting proper identification. Upon making a request you may receive a copy of your report via mail. Under Section (a)(2)(B)(vi) of the California Civil Code, you are notified that Insight privacy practices can be found at Under Section of the California Civil Code and Section of the California Labor Code, you are notified that a credit report may be ordered if you are applying for a position involving access to confidential or proprietary information. Notice to NEW YORK Applicants Under Article 25 Section 380-g of the New York General Business Law, should a consumer report received by an employer contain criminal conviction information, the employer must provide to the applicant or employee who is the subject of the report, a printed or electronic copy of Article 23-A of the New York Correction Law, which governs the employment of persons previously convicted of one or more criminal offenses. APPLICANT SIGNATURE DATE 11

12 CERTIFICATION OF COMPLIANCE WITH DRIVER LICENSE MOTOR CARRIER INSTRUCTIONS: The requirements in Part 383 apply to every driver who operates in intrastate, interstate, or foreign commerce and operates a vehicle weighing 26,001 pounds or more, can transport more than 15 people, or transports hazardous materials that require placarding. The requirements in Part 391 apply to every driver who operates in interstate commerce and operates a vehicle weighing 10,001 pounds or more, can transport more than 15 people, or transports hazardous materials that require placarding. DRIVER REQUIREMENTS: Parts 383 and 391 of the Federal Motor Carrier Safety Regulations contain some requirements that you as a driver must comply with. These requirements are in effect as of July 1, They are as follows: 1. You, as a commercial vehicle driver, may not possess more than one license. 2. If you currently have more than one license, you should keep the license from your state of residence, and return the additional licenses to the states that issued them. Destroying a license does not close the record in the state that issued it; you must notify the state. If a multiple license has been lost, stolen, or destroyed, you should close your record by notifying the state of issuance that you no longer want to be licensed by that state. 3. Sections and of the Federal Motor Carrier Safety Regulations require that you notify your employer the NEXT BUSINESS DAY of any revocation or suspension of your driver's license. In addition, Section requires that any time you violate a state or local traffic law (other than parking), you must report it to your employing motor carrier and the state that issued your license within 30 days. DRIVER CERTIFICATION: I certify that I have read and understand the above requirements. The following license is the only one I will possess: License #: State: Exp. Date: Applicant Signature: Date: 12

13 Part A - CERTIFICATION OF VIOLATIONS ANNUAL REVIEW OF DRIVING RECORD (49 CFR ) / (49 CFR ) Driver Name: MOTOR CARRIER INSTRUCTIONS: The Company is required by the DOT to perform an annual records check, to ensure the company is aware of any and all traffic violations committed by its drivers, including those in a private auto as well as any in a Commercial Motor Vehicle. Please list on the following lines all violations of motor vehicle traffic laws and ordinances (other than violations for parking only) of which you have been convicted, or on account of which you have forfeited bond or collateral during the last 12 months. (Per FMCSR ) I certify that the following is a true and complete list of traffic violations required to be listed for which I have been convicted or forfeited bond or collateral during the past 12 months. DATE Offense Location Type of Vehicle Operated If no violations are listed above, I certify that I have not been convicted or forfeited bond or collateral on account of any violation (other than those I have provided under Part 383) required to be listed during the past 12 months. Driver Signature: Date of Certification: Driver License #: State: Expiration Date: Part B MVR (attached) Attach a copy of your Motor Vehicle Report to the back of this application. If you are selected for employment with Southwest Traders, you may be required to provide another copy should the attached MVR be more than 30 days old at your date of hire. Part C - Carriers Annual Review Carrier's annual review of driving record and certification of continued qualification as required by FMCSR (c)(2) This day I have reviewed the driving record of the above named driver in accordance with of the FMCSRs. I considered any evidence that the driver has violated applicable provisions of the FMCSRs and the HMRs (if applicable). I considered the driver's accident record and any evidence that he/she has violated any laws governing the operation of motor vehicles, and gave great weight to violations, such as speeding, reckless driving, and operation while under the influence of alcohol or controlled substances, that indicate the driver has exhibited a disregard for the safety of the public. Having done so, I find that: ( ) The driver meets the minimum requirements for safe driving, or ( ) The driver is disqualified to drive a motor vehicle pursuant to Motor Carrier s Name: Southwest Traders, Inc. Motor Carrier s Address: Diaz Ave. Temecula, CA Reviewed By Signature: Title: Date: 13

14 SAFETY PERFORMANCE HISTORY RECORDS REQUEST (49 CFR (A) (2) & (C)) / (49 CFR (A) & (B)) / (49 CFR (A) & (C)) RECIPIENT EMPLOYER: The Individual identified in SECTION 1 below has indicated that you employ(ed) or use(d) him/her within the last 3 years in a position that involved the operation of a commercial motor vehicle and/or that was subject to U.S. Department of Transportation (DOT)-regulated drug and alcohol testing. In accordance with 40 CFR and , we are hereby requesting that you supply us with the Safety Performance History of this individual. Under DOT rule (g), you must respond to this inquiry within 30 days of receipt. Please complete SECTIONS 2 through 4 (as applicable) and return to the prospective employer shown in SECTION 1. APPLICANT: Complete SECTION 1 and submit to prospective employer. PROSPECTIVE EMPLOYER: Complete SECTION 5a and send form to current/previous employer. Upon receipt of completed form, complete SECTION 5b and retain. SECTION 1: TO BE COMPLETED BY PROSPECTIVE EMPLOYEE I, (Print Name) First, M.L., Last Social Security Number Hereby Authorize Date of Birth Previous Employer: Street: Telephone: City, State, Zip: Fax No.: to release and forward the information requested by section 4 of this document concerning my Alcohol and Controlled Substances Testing records within the previous 3 years from. (date of employment application) To: Prospective Employer: Southwest Traders, Inc. Attention: Human Resources Department / Recruiter Telephone: Street: Diaz Road City, State, Zip: Temecula, CA In compliance with 40.25(g) and (h), release of this information must be made in a written form that ensures confidentiality, such as fax, , or letter. Prospective employer s confidential fax number: Prospective employer s confidential address: Applicant s Signature Date SECTION 2: TO BE COMPLETED BY PREVIOUS EMPLOYER EMPLOYMENT VERIFICATION The applicant named above was or is employed or used by us. Yes No Employed as (job title) from (m/y) to (m/y) Did he/she drive a motor vehicle for you? Yes No If yes, what type? Straight Truck Tractor-Semitrailer Bus Cargo Tank Doubles/Triples Other (Specify) Completed by: Company: Street: City, State, Zip: Telephone: Signature: Date: If there is no safety performance history to report, check here and return. Otherwise, complete Sections 3 and 4 on page 2 and return. 14

15 PAGE 2 SECTION 3: Employee Name Date: TO BE COMPLETED BY PREVIOUS EMPLOYER ACCIDENT HISTORY Complete the following for any accidents included on your accident register ( (b)) that involved the applicant in the 3 years prior to the application date shown on SIDE 1 or check here if there is no accident register data for this driver. Date Location No. of Injuries No. of Fatalities Hazmat Spill Please provide information concerning any other commercial motor vehicle accidents involving the applicant that were reported to government agencies or insurers or retained under internal company policies: SECTION 4: TO BE COMPLETED BY PREVIOUS EMPLOYER DRUG AND ALCOHOL HISTORY If applicant was not subject to DOT testing requirements under 49 CFR Part 40 while employed by you, please check here and return. Applicant was subject to DOT testing requirements from to. In answering these questions, include any required DOT drug or alcohol testing information you obtained from other employers in the 3 years prior to the application date shown on SIDE 1. Within the past 3 years from the application date shown on SIDE 1: 1. Has this person violated any of the drug and/or alcohol prohibitions under 49 CFR Part 40 or Subpart B of Part 382, including: An alcohol test with a result of 0.04 or higher alcohol concentration. A controlled substances test of result of positive, adulterated, or substituted. A refusal to submit to a random, post-accident, reasonable-suspicion, or follow-up controlled substances or alcohol test. Alcohol use while performing or within 4 hours before performing safety-sensitive functions. Alcohol use after an accident, in violation of Controlled substances use while on duty, except as allowed under If this person violated a DOT drug and/or alcohol prohibition, did he/she fail to begin or complete a rehabilitation program prescribed by a Substance Abuse Professional (SAP)? If rehabilitation was required but you do not know if he/she began or completed such program, check here. YES NO N/A 3. If this person successfully completed a SAP s rehabilitation referral and remained in your employ, did he/she subsequently have an alcohol test result of 0.04 or greater, a verified positive drug test, or refusal to be tested? SECTION 5A: TO BE COMPLETED BY PROSPECTIVE EMPLOYER This form was (check one) Faxed to previous employer Mailed ed Other By: Date: Subsequent attempts to contact previous employer ( (c)(1)): SECTION 5B: TO BE COMPLETED BY PROSPECTIVE EMPLOYER Complete below when information is obtained. Information received from: Recorded by: Method: Fax Mail Telephone Date: Other 15

16 DRIVERS ROAD TEST EXAMINATION Driver s Name: Phone Number: Driver s Address: City: State: Zip Code: Rating of Performance PASS FAIL The pre-trip inspection (As required by Sec ) Coupling and uncoupling of combination units, if the equipment he or she may drive includes combination units Placing the equipment in operation Use of vehicle's controls and emergency equipment Operating the vehicle in traffic and while passing other vehicles Turning the vehicle Braking and slowing the vehicle by means other than braking Backing and parking the vehicle Other, Explain: Type of equipment used while performing test: Examiners Signature: Date: Additional Remarks: 16

17 CERTIFICATION OF ROAD TEST (49 CFR ) Company Name: Southwest Traders, Inc. Driver s Name: Social Security Number: Driver License Number: State: Expiration Date: Type of Power Unit: Type of Trailers: This is to Certify that the above-named driver was given a road test under my supervision on DATE: Consisting of approximately (How many Miles of driving): It is my opinion that this driver possesses the necessary driving experience to operate the type of commercial motor vehicle listed above. Signature of Examiner: Title: Company Name: Southwest Traders, Inc. Address of Examiner: 17

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