DRIVER’S APPLICATION FOR EMPLOYMENT

LAST THREE-YEAR ADDRESS HISTORY

From or Before To Current Unit No/Street No/Street Name City Prov. Postal Code

DRIVER LICENSE INFORMATION

Issuing Province Driver License Number Driver License Class Driver License Condition Driver License Expiry Date
1. Do you hold driver license in any other jurisdiction other than the mentioned above or do you hold any driver license in any other name?
2. Have you ever been denied a license, permit or privilege to operate a motor vehicle?
3. Has any license, permit or privilege ever been suspended or revoked?
4. Has you ever tested positive or refused to submit alcohol or controlled substance test?
5. Have you any injury or medical condition which might affect your job (convulsive disorder, epilepsy, fainting, or heart disease etc.)?

DRIVING EXPERIENCE

Yrs
Yrs
Yrs
Yrs
Yrs
Yrs
Yrs
Yrs
Yrs
Yrs
Yrs
Yrs

EMPLOYMENT HISTORY

INSTRUCTIONS: (1) The applicant must provide the following information on all employers during the preceding 3 years (2) Provide additional 7 years information on those employers for whom the applicant operated commercial motor vehicle (3) Provide complete mailing address, street number, city, state, and postal code (4) Do not write “See resume” in this section (5) List employers in reverse order starting with the most recent. Add another sheet as necessary.

Name of Employer:
Complete Address:
Contact Person:
Position Held:
Reason for Leaving:
Driving Experience:
Were you subject to the FMCSRs while employed?
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?

ACCIDENT RECORD

Accident record for past 3 years (attach sheet if more space is needed)

Date Location Nature of Accident (Rollover/Head-On/Back End etc.) No of Fatalities No of Injuries Hazardous Material Spill

TRAFFIC CONVICTIONS

Traffic convictions and penalties for the past 3 years (other than parking violations)

'
Date Location Charge Penalty ($)

TO BE READ AND SIGNED BY APPLICANT

I understand that information I provide regarding current and/or previous employers may be used, and those employer(s) will be contacted, for the purpose of investigating my safety performance history.

I authorize my prospect employer 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.

I agree that, if hired, I will immediately inform my employer in writing of any violations or accidents that occur while I am operating any motor vehicle. I will also immediately inform my employer of any suspensions, restrictions, prohibitions, or any other change in the status of my driver’s license.

By signing this application, I certify 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. In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the Company.

I here by give my consent and authorize my prospect employer, to contact my previous employer(s) in order to verify my Employment History, Safety Performance History and Drug & Alcohol History and to obtain the following information. I release my prospective and previous employer(s) and its employee(s) from any and all liabilities which may result from furnishing such information.

EMPLOYMENT VERIFICATION / REFERENCE CHECK

(TO BE FILLED BY THE PREVIOUS EMPLOYER)

1. The applicant named above was employed by us as from to

2. Did he drive commercial motor vehicle for you?

If Yes what type of:

3. How do you overall rate the applicant’s performance?

4. Reason for leaving the employment.

5. Complete the following if the applicant was involved in any accident/incident which is on your accident register or was reported to government agencies or insurance:

Date Description of Accident/Incident & Location No of Injuries No of Fatalities Hazmat Spill

7. He was applicant subject to FMCSR while employed and/or his 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? (If Yes, then please answer)

Has this person had an alcohol test with the result of 0.04 or higher alcohol concentration?
This person tested positive or adulterated or substituted a test specimen for controlled substances?
Has this person refused to submit to a post-accident, random, reasonable suspicion, or follow-up alcohol or controlled substance test?
Has this person committed other violations of Subpart B of Part 382, or Part 40?
If this person has violated a DOT drug and alcohol regulation, did this person complete a SAP-prescribed rehabilitation program in your employ, including return-to-duty and follow-up tests? If yes, please send documentation back with this form.
For a driver who successfully completed a SAP’s rehabilitation referral and remained in your employ, did this driver subsequently have an alcohol test result of 0.04 or greater, a verified positive drug test, or refuse to be tested?

The above information is provided by:

HOURS OF SERVICE RECORD

(FOR THE FIRST TIME OR INTERMITTENT DRIVER)

Day Total On-Duty Hours Day Total On-Duty Hours
01 08
02 09
03 10
04 11
05 12
06 13
07 14

I hereby certify that the information contained herein is true to the best of my knowledge and belief, andthat my last period of release from duty was Date: Time:

THE DRIVER MUST FILL THIS FORM TO DISCLOSE HIS LAST 14 DAYS HOUR OF SERVICE RECORD OR MUST SUBMIT LAST 14 DAYS LOG SHEETS BEFORE HIS FIRST TRIP WITH THE COMPANY. PLEASE TICK THE RELEVANT:

I am providing my last 14 days Hours of Service Record on this form
I will provide original or signed copies of my last 14 days logs on my first working day with this company

COMPANY SAFETY & DISCIPLINARY POLICIES

Health& Safety Policy I have been informed about the company’s Health & Safety Policy i.e. “The company believes that health and safety of our employees, subcontractors, clients and general public is of the utmost importance. The management of the company is committed to provide a safe work environment. To maintain the safe work environment, we need and insist upon the full cooperation from everyone working for the company including employees, subcontractor and management. We all must take personal responsibility for their actions and comply with all relevant laws, regulations, policies and procedures. Total commitment to the Safety Program by everyone, every day, is required.”
Employee Commitment and Right to Refuse to Work I understand that it is my responsibility to inform the company of any incident or safety concerns which might affect me to perform my job safely. Failure to inform the company of any incident or safety concerns before refusing to work would be a violation of this policy grounds for disciplinary action by company management. I understand that I will not operate commercial vehicle if the vehicle or any equipment related to the commercial vehicle is in a condition likely to cause danger to persons or property. I must also immediately inform the company about such situations. I have been informed and understand that as per the company policy the employee has right to refuse to perform the work that (i) he orshe believes presents animminent danger to the health orsafety of themselves or their fellow workers, and/or (ii) He/she is not competent to perform.
Speed Limits I am aware that when operating company owned or leased vehicles it is my lawful duty to comply with the posted speed limit and all local By-Laws. Failure to comply with this policy is grounds for disciplinary action by company management.
Use of Seat Belts I understand that it is my responsibility to wear my seat belt while operating any company owned or leased vehicle. Any breach of the policy is grounds for disciplinary action by company management.
Defensive Driving I understand that I will operate company vehicles in a professional and courteous manner. I will remain prepared to avoid collision causing situations by practicing and by promoting the principles of defensive driving. I will leave a safe distance between vehicles, always keep the vehicle under control and be prepared for changes in road, weather and traffic conditions. I will also obey distracted driving and all applicable laws while driving.
Accident/ Violation Reporting I understand that it is my responsibility to immediately inform the company about all the violation tickets / roadside CVSA inspection / accidents / incidents I am involved in. This rule applies to while driving any vehicleincludingcompanyvehicles, my private vehicleand/oroperating othercarrier’s vehicles.
Driver's License Policy I understand that it is my responsibility to inform the company management of any traffic violations filed against me while driving a company vehicle or any personal vehicle. I agree to inform the company if my driver's license has been suspended for any reason and I shall immediately inform the company of the suspension the reason of the suspension and the duration of the suspension. I also agree to supply the company with a copy of my current driver's license, and a copy every time thereafter when my license is renewed/ changed/ updated. I also agree to advise the company of the date when my medical examination isdue. Iagree andunderstand thatif Ihavenotpassed the medicalexamination by the medical due date, I will not be permitted to drive company vehicles.
Alcohol and Drug Policy I understand that as per company policy the possession and/or consumption and/or being under influence of alcohol, controlled substance, or the misuse of prescription drugs are strictly prohibited while on-duty. It is unacceptable and also illegal to be on duty while under the influence of drug/alcohol any intoxication, which can affect my performance at work. I am aware of the potential danger of such an action and therefore agree that I will be dismissed immediately without any recourse if I violate / breach Alcohol and Drug Policy of the company. All drivers, upon company’s discretion, will be subject to testing in the following circumstances (i) Pre-employment drug/alcohol test at the time of hiring (ii) At the time of any incident or accident (iii) Testing will also take place whenever the company has a reasonable ground to believe that, the actions, appearance and/or conduct of an employee are indicative of the use of drugs or alcohol (i.e. smell, change in physical appearance, behavior or speech pattern observed)
Trip Inspections I have been informed about trip inspection regulation and fully understand them. I must complete daily trip inspection in accordance with the NSC Schedule 1. I will submit all roadside inspection reports to the company immediately upon completion of the trip. I understand and agree will not operate the company vehicle with a major defect.
Hours of Service I have been informed of and understand the hours of service regulations. I am aware that I must arrange my work scheduletocomply with these regulations. Iagree to submita record ofallon-duty hours accumulated while working for other operators/employers. All the supporting record i.e. fuel receipts, border crossing, pick & drop times much match with the daily logs. Violating HOS regulation or falsifying logs is strictly prohibited under the company policy and is grounds for disciplinary action by company management.
Load Securement I have been informed of and understand the load securement regulations. I will ensure that all any cargo transported on company vehicles is contained, immobilized or secured in according to NSC Standard 10. I will be following the general guidelines for ensuring that the cargo is secured, and it must not
(i) Leak, spill, blow off, fall from, fall through or otherwise dislodge from the commercial vehicle; or (ii) Shift upon or within the commercial vehicle to such an extent that the commercial vehicle’s stability or maneuverability is adversely affected. I will check cargo securement at the time of (i) Starting the trip (ii) After first hour of the driving/trip (iii) after that every three hours of driving/trip
Weights & Dimensions I have been informed about application Weights & Dimension regulation and I fully understand them. I understand that, if necessary, I must check gross weight / axle weight after picking up the load and obtain weight slips, where applicable. I will ensure that the vehicle has legal weight & dimension while on the public roads.
Bill of Lading& Waybills The driver must ensure that the Bill of Landing & Waybills are complete in every respect and has all the necessary information.
Dangerous Goods Documents While picking up dangerous goods load, I understands that I must ensure proper placards are attached on all four sides of the vehicle and the Dangerous Goods Shipping Document must contain, at minimum, the following information (i) Consignor’s name and address (ii) Date of shipment (iii) Description of the Dangerous Goods (iv) Quantity of dangerous goods (v) The “24-hour number” (vi) The consignor’s certification. I understand that the shipping documents must be carried within the driver’s reach preferably pocket on the driver’s seat. If the vehicle is left in a supervised area, a copy of the shipping document must be left with the person in-charge.
Vehicle Passengers I understand that it is the company's policy that there be no passenger in accompany owned or leased vehicle without prior written consent from company management. It is also my responsibility to inform company management of anyone who intends to ride in a company owned or leased vehicle prior to driving that vehicle.
Use of Warning Devices During any time the company vehicle will not be stationary on a highway outside the limits of an urban area unless (i) The hazard lights are alight (ii) Advanced warning triangles are placed without delay on the highway in line with the commercial vehicle ata distance of approximately 30 meters during the night time and 75 meters during the day time and during insufficient light or conditions where objects are not clearly discernable at 150meters
Daytime Running Lights I understand that it is my responsibility to ensure proper function of daytime running lights on any vehicle that I am operating. Failure to comply with this policy is grounds for disciplinary action by company management.
Disciplinary Action Policy I understand that the company may take and document disciplinary action with employees for any (i) Regulatory violations (identified on the Carrier Profile or driver abstract) and/or (ii) Violation of company policy (ies). Disciplinary actions taken by the company will be progressive in nature. As appropriate, disciplinary action may include (i) Verbal or Written warnings (ii) Suspension without pay (iii) Termination. For severe violations that pose a significant risk to public safety, the company may take any disciplinary action at any stage based on the severity of the violation. I also understand that if I have several incidents in a short period of time. I will be subject to re-training and re-testing again, subject to the severity of the incident(s).
Notice Period I understand that the company will require me to provide a resignation notice period of minimum 10 business days in case I wish to leave the job. Employer will also have to serve a notice of 10 days before relieving me of my duties.