APPLICATION FOR QUALIFICATION Step 1 of 11 9% Driver Email Address: 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 ApplicantPlease answer all questions. If the answer to any question is "No" or ‘None", do not leave the item blank, but write "to” or "None”.Date Position applying for; Check One:ContractorDriverContractor's DriverName (First) (Middle) (Last) Current & Three Years Previous Addresses:FromTo Phone NumberEmergency Phone NumberAgeDate of Birth Social Security Number*The Age Discrimination of Employment Act of 1967 prohibits discrimination on the basis of ages with respect to individuals who are at least 40 but less than 70 yeas of age.Physical Exam Expiration Date: Driver's License # and StateHave you worked for this company before?YesNolf yes, give dates:FromToReason for leaving?Education HistoryPlease check the highest grade completed:Grade School123456789101112College1234Post-Graduate1234 Employment History - 10 yearsGive a Complete Record of all employment for the past 10 years, including any unemployment or self. employment, and all commercial driving experience for the past ten years.Mo/YrFromMo/YrToPresent or Last Employer:Name:Position HeldAddress Street City State/ZIP Reason for LeavingPhone #Were you subject to the FMCSRs* while employed here?YesNoWas 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?YesNoMo/YrFromMo/YrToPresent or Last Employer:Name:Position HeldReason for LeavingPhone #Address Street City State/ZIP Were you subject to the FMCSRs* while employed here?YesNoWas 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?YesNoMo/YrFromMo/YrToPresent or Last Employer:Name:Position HeldReason for LeavingPhone #Address Street City State/ZIP Were you subject to the FMCSRs* while employed here?YesNoWas 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?YesNoMo/YrFromMo/YrToPresent or Last Employer:Name:Position HeldReason for LeavingPhone #Address Street City State/ZIP Were you subject to the FMCSRs* while employed here?YesNoWas 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?YesNoMo/YrFromMo/YrToPresent or Last Employer:Name:Position HeldReason for LeavingPhone #Address Street City State/ZIP Were you subject to the FMCSRs* while employed here?YesNoWas 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?YesNo“The Federal Motor Carrier Safety Regulations (FMCSRs) apply to anyone who operates a motor vehicle on a highway in interstate commerce to transport passengers 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 ExperienceClass of EquipmentDates (From)Dates (To)Approximate Number of Miles (Total) Straight TruckTractor 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 past three years (attach sheet if more space is needed)Date of AccidentNature of Accidents (Head on, rear end, upset, etc.)Location of Accident# of Fatalities# of People Injured Traffic Conviction and Forfeitures for the Last three years (other than parking violations)DateLocationChargePenalty Driver’s License (list each driver’s license held in the past three years)DateLicense #TypeEndorsementsExpiration Date A. Have you ever been denied a license, permit or privilege to operate a motor vehicle?YesNoB. Has any license, permit or privilege ever been suspended or revoked?YesNoC. 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)?YesNoD. Have you ever been convicted of a felony?YesNoIf the answers to A, B, C or D is "YES”, give detailsPersonal ReferencesList three persons for references, other than family members, who have knowledge of your safety habits.NameAddressPhoneNameAddressPhoneNameAddressPhone To Be Read and Signed by ApplicantIt 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, whether 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 agreed and understood that under the Fair Credit Reporting Act, Public Law 91-508; I have been told that this investigation may include an investigating 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. Applicant SignatureDate DRIVER’S RIGHTS PERTAINING TO RELEASE OF DRIVER INFORMATION UNDER REGULATION 391.23Motor carriers have the responsibilities 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 continuous period which began before January 1, 1971. (a)(l) An inquiry into the driver’s driving record during the preceding 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 data of the employment application, and any accidents the previous employer may wish to provide. (e)Prospective 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 49 CFR Part 40. Drivers have the following rights The right to review information provided by previous employers. 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. The right to have a rebuttal statement attached to the alleged erroneous information, if the previous employer and the driver cannot agree on the accuracy of the information. Drives who wish to review previous employer-provided investigative information must submit a written request to the prospective employer when applying or as late as 30 days after employed 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 requested 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 with in 15 days of receiving the driver, request to correct the data that It does not agree to correct the data. Drivers wishing to rebut information in records must send the rebuttal to the previous employer with instruction to include the rebuttal in the driver’s Safety Performance History. I acknowledge that I have read and understand the contents of this document Driver's SignatureDate Driver Name (Printed): DRIVER APPLICANT DRUG ALCOHOL PRE-EMPLOYMENT STATEMENTCFR 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, we 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:(Please Print)ID Number: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.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?YesNo2) If you answered yes, to the above question, can you provide proof that you’ve successfully completed the DOT return-to-duty requirements?YesNoMy signature below certifies that the information provided is true and correct.Applicant Signature:Date CONTROLLED SUBSTANCE & ALCOHOL TESTING INFORMATION ACKNOWLEDGEMENT/CONSENT FORMAs a condition of employment with MWCCI, Commercial Motor Vehicle (CMV) Driver Applicants must submit to a pre-employment controlled substances test as required by tho Federal Motor Carrier Safaty Regulations (FMCSR) Section 382.301. A motor carrier must receive verified negative test results for the applicant driver for the applicant to be eligible for employment. If you are hired, you will be subject to laws requiring additional controlled substances and alcohol testing on you under numerous situations including, but not limited to, the following: Post-Accident — Section 382.303 Random- Section 382.305 Reasonable Suspicion - Section 382.307 Return to Duty - Section 382.308 Follow-up - Section 382.31 1 A Driver who tests positive to a controlled substance(s) and/or alcohol test, will be immediately removed from a safety-sensitive position as required by Part 382 of the FMCSR. Federal law prohibits a Driver from returning to a safety-sensitive position for any motor carrier until and unless the Driver completes the Substance Abuse Professionals (SAP) evaluation, referral and educational/treatment process, as described in FMCSR Part 40, Subpart O. The following is a referral list of Substance Abuse Professionals: (to be completed by Carrier)NameAddressPhone#All controlled substance and alcohol testing will be conducted in accordance with Parts 40 and 382 of the FMCSR I(Print Name)have read the above controlled substances and alcohol testing requirements and understand them. I acknowledge receipt of the referral list of Substances Abuse Professionals. Applicant's SignatureDate Employer Representative Request for Driver's Safety Performance History Information from DOT Regulated Previous Employer(s) Driver to complete this sectionAs a Commercial Motor Vehicle (CMV) Driver, I understand that per the Federal Motor Carrier Safety Regulations (FMCSRs) Part 391.21, the following information will be requested from all previous Employers for which I operated a CMV, subject to the FMCSR Parts 390 and/or 40, 382 & 383, within the past three years, from date shown below. I also acknowledge that this information will be used in determining my eligibility to be hired, that I have the right to review this information and rebut any errors in these statements from my prior employers, as described in the FMCSR Part 391.23. Ion this date hereby authorize this Company to release all records of employment, including assessments of my job performance, ability and fitness (including dates of any and all alcohol or drug tests, those confirmed results and/or my refusal to submit to any alcohol or drug tests and any rehabilitation completion under direction of(SAP/MRO) to each and every company (or their authorized agents) which may request such information in connection with my application for employment with said company. I hereby release this company, and its employees, officers, directors, and agents from any and all liability of any type as a result of providing information to the above mentioned person and/or Company.Previous Employer:Contact Person:Mailing Address:City, State, Zip:Telephone Number:Fax Number:I worked for this Companyfrom the dates ofTo Applicant’s signatureSSN:D.O.B SECTION I - Past Employer to Complete > DRUG & ALCOHOL INFORMATIONPlease provide the following Drug and Alcohol information as required by FMCSR Part 39J.23 & 40.25. If no Drug and Alcohol information is available on above named applicant Check here. 1. Any alcohol test with a result of 0.04 or higher alcohol concentration?YesNo2. Any verified positive drug test?YesNo3. Any refusals to be tested (including verified adulterated or substituted drug test results?)YesNo4. Any other violations of DOT agency drug & alcohol testing regulations (Part 382 or Part 40)?YesNo5. If this Driver did successfully complete a SAP rehabilitation referral and remained in your employ, did he/she have any subsequent violations for, an Alcohol test result of 0.04 or greater, a verified positive drug test or a refusal to test(including a verified adulterated/substituted drug test result?)YesNo6. If yes to any of the above questions, please provide documentation of successful completion of a SAP evaluation, prescribed treatment and return-to-duty requirement (including follow-up tests) if they remained in your employ*. * If this information is not available from the previous employer, you as a prospective employer, must get this information from the Driver/Applicant. Drug and Alcohol information needs to be kept in a separate personnel and/or Confidential file Request for Driver’s Safety Performance History Information from BOT Regulated Previous Employer(s)SECTION II - Past Employer to Complete >> ACCIDENT INFORMATIONPlease provide the following information as required by 391.23(d) (I) (2) on any accidents, as defined by 390.5 and/or from your Accident Register(FMCSR 391.15) which the above named Driver/Applicant was involved within the past three years while under your employment. Previous employers may include additional detailed information on minor accidents/incidents at their discretion. If there is no accident information for this driver please check here. DateLocation ( Please give city/town or most near & state)Any Vehicles Towed?HazMat Spill?# of Fatalities ?# of Injuries? SECTION III- Past Employer to Complete >> WORK HISTORYINFORMATIONPlease provide the following information on the above name Driver/ApplicantHe/She was employed for you as a:DatefromTo If employed as a Driver, what type of equipment did he/she operate? Straight Trucks Tractor/Trailer Doubles Triples Other Explain:Type of Trailer(s) pulled:Was he /she a: Company Driver?YesNoContractor?YesNoContractor’s Driver?YesNoOther?YesNoGeneral area traveled:Commodities transport:While under your employment was he/she:a. Bonded:YesNob. Convicted of any traffic violations:YesNoIf yes, please list all, including date and type:c. License(s) suspended, revoked or denied:YesNoIf yes, please explain:Reason for leaving:Would you re-employ this person:YesNoUpon ReviewPlease explain:Additional Comment:Previous Employer Representative Supplying Information: Print NameTitleSignatureDate MANDATORY USE FOR ALL ACCOUNT HOLDER *49CFR *382.405 *382.413Important NoticeREGARDING BACKGROUND REPORTS FROM THE PSP Online Service1 . In connection with your application for employment with MWCCI, its employees, agents or contractors may obtain one or more reports regarding your driving, and safety inspection history from the Federal Motor Carrier Safety Administration (FMCSA). When the application for employment is submitted in person, if the Prospective Employer uses any information it obtains from FMCSA in a decision to not hire you or to make any other adverse employment decision regarding you, the Prospective Employer will provide you with a copy of the report upon which its decision was based and a written summary of your rights under the Fair Credit Reporting Act before taking any final adverse action. If any find adverse action is taken against you based upon your driving history or safety report, the Prospective Employer will notify you that the action has been taken and that the action was based in part or in whole on this report. When the application for employment is submitted by mail, telephone, computer, or other similar means, if the Prospective Employer uses any information it obtains from FMCSA in a decision to not hire you or to make any other adverse employment decision regarding you, the Prospective Employer must provide you within three business days of taking adverse action oral, written or electronic notification: that adverse action has been taken based in whole or in part on information obtained from FMCSA; the name, address, and the toll free telephone number of FMCSA did not make the decision to take the adverse action and is unable to provide you the specific reasons why the adverse action was taken; and that you may, upon providing proper identification, request a free copy of the report and may dispute with the FMCSA the accuracy or completeness of any information or report. If you request a copy of a driver record from the Prospective Employer who procured the report, then, within 3 business days of receiving your request, together with proper identification, the Prospective Employer must send or provide to you a copy of your report and a summary of your rights under the Fair Credit Reporting Act. The Prospective Employer cannot obtain background reports from FMCSA unless you consent in writing. I authorize MWCCI to access the FMCSA Pre-Employment Screening Program (PSP) system to seek information regarding my commercial driving safety record and information regarding my safety inspection history. I understand that I am consenting to the release of safety performance information including crash data from the previous five (5) years and inspection history from the previous three (3) years. I understand and acknowledge that this release of information may assist the Prospective Employer to make a determination regarding my suitability as an employee. 3. I further understand that neither the Prospective Employer not the FMCSA contractor supplying the crash and safety information has the capability to correct any safety data that appears to be incorrect. I understand I may challenge the accuracy of the data by submitting a request to https://dataqs.fmcsa.dot.gov. If i am challenging crash or inspection information reported by a State, FMCSA cannot change or correct this data. I understand my request will be forwarded by the DataQs system to the appropriate State for adjudication. 4. Please note: Any crash or inspection in which you were involved will display on your PSP report. Since the PSP report does not report, or assign, or imply fault, it will include all Commercial Motor Vehicle (CMV) crashes where you were a driver or co-driver and where those crashes were reported to FMCSA , regardless of fault. Similarly , all inspections, with or without violations, appear on the PSP report, State citations associated with FMCSR violations that have been adjudicated by a court of law will also appear, and remain, on a PSP report. I have read the above Notice Regarding background Reports provided to me by Prospective Employer and I understand that if I sign this consent form, Prospective Employer may obtain a report of my crash and inspection history. I hereby authorize Prospective Employer and its employees, authorized agents, and/or affiliates to obtain the information authorized above.Date SignatureName (Please Print) APPLICANT AUTHORIZATION CONSENT FOR RELEASE OF INFORMATIONMWCCI requires , as a condition of employment, and/or continued employment, that all applicants consent to and authorize a verification submitted on their applications or resume. Please read this statement carefully I, the undersigned applicant, do hereby certify that the information provided by me for the purpose of employment is true and complete to the best of my knowledge, I understand that if I am employed my false statement will be considered as cause for possible dismissal. This release and authorization acknowledge that this Company may now , or at any time while I am employed, conduct a verification of my education, employment history, social security and, credit history, motor vehicle records, to contact a personal reference, and to receive any criminal history record information pertaining to me which may be in the files of any Federal, State, or Local criminal justice agency in any state, and/or other information as deemed necessary to fulfill the job requirements. Also, if an offer of employment has been made, I authorize review of my worker's compensation claim history. I authorize MCS, Inc. and any of the agents and/or employees to disclose orally and in writing the results of the verification process to the designated authorized representatives of this Company. The results will be used to determine employment eligibility under this Company's employment policies. I have read and understand this release and consent, and I authorize the background verification. I authorize person, schools, current and former employers, and other organizations and agencies to provide MCS, Inc. with all information that may be requested, and I hereby release all of the personals and agencies providing such information from any end all claims and damages connected with their release of any requested information. I agree that any copy of this document is a valid as the original. I do hereby agree to forever releases and discharge this Company, its agents, MCS, Inc. and their associates to the full extent permitted by law from any claims damages, losses, liabilities, costs. and expenses, or any other charge or complaint filed with any agency arising from the retrieving and reporting of information. According to the Federal Fair Credit Reporting Act, I am entitled to know if employment was denier information obtained by my prospective employer, and to receive, upon written request, a disclosure of the public record information and of the nature and scope of the investigative report. Please provide all requested information and provide addresses for the last seven (7) years:Applicant's Name, Priinted- Last First Middle Maiden or other name(s) used Current Address Street City State Zip CountyHow long at this addressPrevious Address Street City State Zip CountyHow long at this addressPrevious Address Street City State Zip CountyHow long at this addressSocial Security NumberDate of birth- for the confirmation of ID only Name- exactly it appears on driver's licenseDriver's license NumberStateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificAuthorization to contact present employer for referenceYesNoSignatureDate This iframe contains the logic required to handle Ajax powered Gravity Forms.