Thefollowingpoliciesandprocedureswillapplytoallprospectiveandcurrentemployeesthathaveaccesstooroperate company-ownedvehicles:
•Applicantswillnotbeconsideredforemployment ifthey:
oHavebeenconvicted ofaDUI,recklessdriving orrefusaltosubmitwithinthelastthreeyears
oHavehadanycombination ofthreemoving violations and/oraccidentswithinthelastthreeyearso Havehadmorethanoneat-faultaccident withinthelastthreeyears
•Amotorvehiclerecord(MVR)checkmustbecompletedprior toanyemployeeplacement inregularemployment.
•MVR'swillberequestedandreviewedeverytwelve months(perD.O.T.Regulations) forallemployeeshavingaccesstoorwhooperateacompany-ownedvehicle.
•Iftheemployeereceivestwoormoremoving violationsorhastwoormoreat-faultaccidents ofanytypeoranycombination ofmovingviolationsandat-faultaccidents,theemployeewillberequiredtoattendadefensive drivingschool(attheirownexpense) andwillbeplacedonasixmonthprobationaryperiod.
•Athirdmovingviolation,anadditionalat-faultaccidentorDUIconvictionmayresultinthelossofyourprivilegetooperateacompany-ownedvehicle,employmentsuspensionand/ortermination.
•Recklessuseofacompany-ownedvehicleand/oranat-faultaccidentinvolvingacompany-ownedvehiclemayresultinprobation,lossofcompanydriving privileges,employmentsuspension and/ortermination.
•Iagree thatmypayfortrainingwillbepaidatminimumwagerate,whichispresently$7.50perhour.
•UniformsmustbeturnedinonorbeforeWednesday priortoyourlastpaycheck.
•AlldriverapplicantsmustfurnishacopyoftheircurrentMVR.
Itisourmutualresponsibilitytomakesure,tothebestofourabilities,thatthecompanyoperatesitsfleetassafelyaspossible.Thisincludeshiringnewemployeesthataresafedriversandbyencouraging current
employeestooperateourvehiclesandtheirown personalvehicles inthesafestmannerpossible.
Imeetthesestandards.
XApplicantSignature
ALLDRIVERAPPLICANTSAREREQUIREDTOFURNISHACOPYOFTHEIRCURRENT MOTOR VEHICLERECORD.(
ACKNOWLEDGEMENTAUTHORIZATIONFORM
I,
Employee (PrintName)
acknowledge receiptof DANALTHOF
TRUCKING,INC.DepartmentofTransportationDrugAlcoholPolicyand Procedures.
ApplicantSignature:
Date:·
*****************************************************************************
AllDANALTHOFFTRUCKING,INC.employeeswillbeprovidedwitheducationandinformationconcerningtheeffectsofalcoholandcontrolledsubstancesuseonanindividual'shealth,workand personal life.Additionally,informationidentifyingsignsandsymptomsofanalcoholoracontrolled substanceproblem (thedriver'sorco-worker's);andavailable methods ofinterveningwhenanalcoholoracontrolled substanceproblem issuspected.
I, acknowledge receiptofAlcoholandDrugawarenessmaterials.
Applicant(Print Name)
Applicant Signature: Date:
****************************************************************************
I, authorizeDANALTHOFFTRCUKINGINC.,torelease
Applicant(Print Name)
anyandallresultsofmycontrolledsubstanceand/oralcoholteststoNationalReviewOffices,Los
Angeles,CA.
ApplicantSignature:Date:
2
PersonalInformation
Name
FirstMiddleLast
Today’sDate:EmailAddress:
TelephoneNumber:
BirthDateIISocialSecurityNumber
CurrentAddress
StreetCityState/ZipHowLong?
Previous Address(es):past3years
Haveyoubeenconvictedofafelony?YesNo
Ifyes,pleaseexplain:
PositionAppliedFor
PositionStart Date Salary?Areyouemployednow?
lfso, maywecontact your present employer?
Willyoubeavailabletoworknightsandweekends?
Howdidyouhearaboutus?
TrafficConvictionsandForfeituresforPastThreeYears
Haveyoueverbeendeniedalicense,permitorprivilegetooperateamotorvehicle? Yes No_Hasanylicenseorpermitprivilegeeverbeensuspendedorrevoked? Yes No_
IftheanswertoeitheroneofthesequestionsisYES,attachaseparatestatementgivingdetails.
Education/Other
U.S.MilitaryorNavalService?_Rank HighestGradeCompleted
References
Name_Telephone Number
Name TelephoneNumber Name TelephoneNumber
Personal
Incaseofemergency,pleasenotify:
Name TelephoneNumber
******
ExperienceandQualifications
Task / Yes / NoVehicle
Inspections
AdjustAirbrakes
TruckLubrication
ChangingTires
AccidentRecordsForPastThreeYears
Occurrence / DateNatureofAccident / Fatalities / InjuriesYes / No / Yes / No
LastAccident
NextAccident
NextAccident
TransmissionTypesDriven / 8speed / 9speed / 10speed / 13speed / Other
LASTEMPLOYER:
EmploymentRecord
NAME: _ADDRESS: PHONE: _
POSITIONHELDFROM:TO SALARY _
REASONSFORLEAVING
ANYGAPSINEMPLOYMENTAND/ORUNEMPLOYMENTMUSTBEEXPLAINED. INCLUDEDATES(MONTH/YEAR)ANDREASON
WereyousubjecttotheFederal MotorCarrierSafetyRegulations(FMCSRs)whileemployedbythepreviousemployer?Yes
No
Wasthepreviousjobpositiondesignatedasasafetysensitivefunction inanyDOTregulated mode,subjecttoalcoholandcontrolled
substancestestingrequirementsasrequiredby49CFRPart40? Yes_
No_
PREVIOUSEMPLOYER:
NAME:
ADDRESS: _PHONE:
POSITIONHELD FROM:_TO SALARY
REASONSFORLEAVING
ANYGAPSIN EMPLOYMENTAND/ORUNEMPLOYMENTMUSTBEEXPLAINED.INCLUDEDATES(MONTH/YEAR)ANDREASON
WereyousubjecttotheFederal MotorCarrierSafetyRegulations(FMCSRs)whileemployedbythepreviousemployer?Yes
No
Wasthepreviousjobpositiondesignatedasasafetysensitivefunction inanyDOTregulated mode,subjecttoalcoholandcontrolled
substancestestingrequirementsasrequiredby49CFRPart40? Yes_
No_
PREVIOUSEMPLOYER:
NAME:
ADDRESS: PHONE:
POSITIONHELD FROM:TO SALARY _REASONSFORLEAVING
ANYGAPSINEMPLOYMENTAND/ORUNEMPLOYMENTMUSTBEEXPLAINED.INCLUDEDATES(MONTH/YEAR)
ANDREASON
EmploymentRecord(cont)
PREVIOUSEMPLOYER:
NAME:
ADDRESS: PHONE:
POSITIONHELD FROM:_TO SALARY
REASONSFORLEAVING
ANYGAPSINEMPLOYMENTAND/ORUNEMPLOYMENTMUSTBEEXPLAINED.INCLUDEDATES(MONTH/YEAR)ANDREASON
WereyousubjecttotheFederal MotorCarrierSafetyRegulations(FMCSRs)whileemployedbythepreviousemployer?Yes
No
Wasthepreviousjobpositiondesignatedasasafetysensitivefunction inanyDOTregulated mode,subjecttoalcoholandcontrolled
substancestestingrequirementsasrequiredby49CFRPart40? Yes_
No_
PREVIOUSEMPLOYER:
NAME:
ADDRESS: PHONE:
POSITIONHELD FROM:_TO SALARY
REASONSFORLEAVING
ANYGAPSINEMPLOYMENTAND/ORUNEMPLOYMENTMUSTBEEXPLAINED.INCLUDEDATES(MONTH/YEAR)ANDREASON
WereyousubjecttotheFederal MotorCarrierSafetyRegulations(FMCSRs)whileemployedbythepreviousemployer?Yes
No
WasthepreviousjobpositiondesignatedasasafetysensitivefunctioninanyDOTregulated mode,subjecttoalcoholandcontrolled
substancestestingrequirementsasrequiredby49CFRPart40? Yes_
No_
PREVIOUSEMPLOYER:
NAME:
ADDRESS: PHONE:
POSITIONHELD FROM:_TO SALARY
REASONSFORLEAVING
ANYGAPSINEMPLOYMENTAND/ORUNEMPLOYMENTMUSTBEEXPLAINED.INCLUDEDATES(MONTH/YEAR)ANDREASON
CertificationofViolations
Icertify thatthefollowingisatrueandcomplete listoftrafficviolations (otherthanparkingviolations) forwhich Ihavebeenconvictedorforfeited bondorcollateral duringthepast12months.
DateOffenseLocationTypeof
VehicleOperated
Ifnoviolationsarelistedabove,IcertifythatI havenotbeenconvicted orforfeitedbondorcollateralonaccount ofanyviolationrequiredtobelistedduringthepast12months.
X
Date ofCertificationDriver'sSignature
Dan AlthoffTrucking,Inc.4600WaldoIndustrialDr.HighRidge,MO.63049
Motor CarrierNameMotorCarrier'sAddress
XHRManager
ReviewedbySignatureTitle
ReviewandEvaluationofDriver’sRecord:
InaccordancewithSection391.25,MotorCarrierSafetyRegulations, allinformationpertinent totheabovedriver'ssafetyofoperations,including thelistofviolations furnished byhiminaccordancewithSection391.27,hasbeenreviewed forthepast12months.
Action Taken
Motor CarrierNameMotorCarrier's Address
PREVIOUSEMPLOYMENTRECORD
To: Date:______From: DanAlthoffTrucking,Inc.
4600WaldoIndustrial Drive
HighRidge,Missouri 63049
(636)677-7772 Fax (636)677-8700
APPLICANTSNAMESOCIALSECURITY#
EmploymentDates:From:
To:
Aretheabovedatescorrect?Yes
No
CorrectDates:
Equipmentoperated:StraightTruckTractor/TrailerDumpOther
CompanyDriverOwner/OperatorOther
AreasOperatedIn? Local
O-T-R
Accidents? YES
NO
DATE
DOTReportable?
Explanation:
Citations?YESNO
DATE
Explanation:
Attendance:
WorkHabits:
EligibleforRe-Hire YES_NO
Review
InformationProvidedBy:
Title:
Iherebyauthorizethiscompanytoreleaseallinformation concerningmyemployment records,includingoralassessments ofmyjobperformance,abilityandfitnesstoeachandeverycompany(ortheirauthorized agents)whichmayrequestsuchinformation inconnection withmyapplicationforemploymentwirhsaidcompany.Iherebyreleasethiscompanyfromanyandallliabilityofanytypeasaresultofprovidingtheabove-mentionedinformationtotheabove-mentionedperson
AuthorizationRequestforDrugandAlcoholHistory
Ifdriver,______SocialSecurity # _wasnotsubjecttoDepartment ofTransportationtestingrequirements whileemployed bythisemployer, pleasecheck here
,fill inthedates ofemploymentfrom
to,signandreturn.
DriverwassubjecttoDepartmentofTransportationtestingrequirementsfrom _to
1.Hasthispersonhadanalcoholtestwiththeresultof0.04orhigheralcoholconcentration?
Yes
No
2.Hasthispersontestedpositiveoradulteratedorsubstituted atestspecimenforcontrolledsubstances?
Yes No__
3.Hasthispersonrefused tosubmit toapost-accident,random, reasonablesuspicion orfollow-upalcohol orcontrolled substancetest?
Yes
No_____
4.Hasthispersoncommitted otherviolationsofSubpartBofPart382orPart40?
Yes
No______
5.IfthispersonhasviolatedaDOTdrugandalcoholregulation,didthispersoncomplete aSAP-Prescribedrehabilitationprogram inyouremploy, includingreturn-to-duty andfollow-uptests?Ifyes,pleasesenddocumentationbackwiththisform.
Yes
No_
6.ForadriverwhosuccessfullycompletedaSAP's rehabilitationreferralandremainedinyouremploy,didthisdriversubsequentlyhaveanalcohol testresultof0.04orgreater,averifiedpositivedrugtest,orrefuse tobetested?
Yes No_
Inansweringthesequestions,includeanyrequired DOTdrugoralcohol testinginformation obtainedfromprevious employersintheprevious3yearspriortothedateonthisform.
Name:Company:Address:
Completed by(Signature):_
Authorized Signature(Prospective Employee)Date
ImportantNotice
TOBEREADANDSIGNEDBYTHEAPPLICANT
Wenormally beginprocessingyourapplication withinonebusinessday,ifyouhaveprovidedcompleteinformation.
Whenprovidingyouremployment history,listalljobsheldwithinthelastthreeyearsandallcommercialdrivingjobswithinthelasttenyears.Youareresponsible forprovidingyourpreviousemployer'stelephonenumber andcompleteaddress.
Also,youmustaccountforallperiodsofemployment orunemployment.Gapsbetweenemploymentor
"missing"timeunacceptable. Ifyouneedadditionalspacetoprovideinformation,attachanothersheettotheapplication.
Applicantsthatsubmitcomplete,accurateinformationareprocessedfirst.
ConsumerReportsmaybeobtainedaspartofmyevaluationofmyjobapplication/employment.Thereportsmaybeprocured byAnderson Insurance Agency, Inc.andmayincludemydrivingrecord,anassessment ofmyinsurability underthecompany'sinsurancecoverage'sorotherconsumer reports.Bysigningthisdisclosure,Ihereby authorize theCompany toprocuresuchreportsandadditionalreportsaboutmefromtimetotime,asitdeems appropriate,toevaluate myinsurability orforotherpermissible purposes.
Name andSocial Security numberofapplicant/employee
Signature
I AUTHORIZEYOUTOMAKESUREINVESTIGATIONSANDINQUIRIESTOMYPERSONAL,EMPLOYMENT,FINANCIALORMEDICALHISTORYANDOTHERRELATEDMATTERSASMAYBENECESSARYINARRIVINGATANEMPLOYMENTDECISION.(GENERALLY,INQUIRIESREGARDINGMEDICALHISTORYWILLBEMADEONLYIFANDAFTERACONDITIONALOFFEROFEMPLOYMENTHASBEENEXTENDED)I HEREBYRELEASEEMPLOYERS,SCHOOLS,HEALTHCAREPROVIDERSANDOTHERPERSONSFROMALLLIABILITYINRESPONDINGTOINGUIRIESANDRELEASINGINFORMATIONINCONNECTIONWITHMYAPPLICATION.
fNTHEEVENTOFEMPLOYMENT,I UNDERSTANDTHATFALSEORMISLEADINGTNFORMATIONGIVENTN MYAPPLICATIONORINTERVIEW(S)MAYRESULTINDISCHARGE.I UNDERSTAND.ALSO.THATIAMREQUIREDTOABIDEBYALLTHERULESANDREGULATJONSOFTHECOMPANY.
1 UNDERSTANDTHATINFORMATIONIPROVIDE REGARDINGCURRENTAND/ORPREVIOUSEMPLOYERSMAYBEUSED,ANDTHOSEEMPLOYER($)WILLBECONTACTED,FORTHEPURPOSEOFINVESTIGATING MYSAFETYPERFORMANCEHISTORYASREGUIREDBY49CFR
391.23(d)AND(e).I UNDERSTANDTHATI HAVETHERIGHTTO:
REVIEWINFORMATIONPROVIDEDBYCURRENT/PREVIOUSEMPLOYERS;
HAVEERRORSTNTHEINFORMATIONCORRECTEDBYPREVIOUSEMPLOYERSANDFORTHOSEPREVIOUSEMPLOYERSTO
RE-SENDTHECORRECTEDINFORMATIONTOTHEPROSPECTIVEEMPLOYER;AND
HAVEAREBUTTALSTATEMENTATTACHEDTOTHEALLEGEDERRONEOUSTNFORMATIONJ,IFTHEPREVIOUSEMPLOYER($)ANDICANNOTAGREEONTHEACCURACYOFTHEINFORMATION.
APPLICANT'SSIGNATUREDATE
THISCERTIFIESTHAT1 HAVECOMPLETEDTHISAPPLICATION,ANDTHATALLENTRIESONITANDINFORMATIONINITARETRUEANDCOMPLETETOTHEBESTOFMYKNOWLEDGE
APPLICANT'SSIGNATUREDATE