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Instructions to Driver

Please answer all questions. If the answer to any question is "No" or "None", do not leave the item blank but write "No" or "None".

Date
Position applying for; Check One
First Name
Middle Name
Last Name
Phone Number
Emergency Phone Number
Age *
Date of Birth

*The Age Discrimination of Employement Act of 1967 prohibits discrimination on the basis of age with respect ot individuals who are at least 40 years of age

Physical Exam Expiration Date

Current & Three Years Previous Addresses:

From
To
From
To
From
To
From
To

Have you worked for this company before?

If yes, give dates:From
To
Reason for leaving ?

Education History

Please Select the highest grade completed:

Grade School :

College : Post-Graduate

Employment History

Give a Complete Record of all employment for the past three years, including any unemployment or self employment, and all commercial driving experience for the past ten years.

Mo/Yr
From
Mo/Yr
To
Present or Last Employer:
Name
Position Held
Address

(street) (City)(State/Zip)

Reason For Leaving
Phone #

Were you subject to the FMCSRs* while employed here ?

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 ?

Mo/Yr
From
Mo/Yr
To
Present or Last Employer:
Name
Position Held
Address

(street) (City)(State/Zip)

Reason For Leaving
Phone #

Were you subject to the FMCSRs* while employed here ?

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 ?

Mo/Yr
From
Mo/Yr
To
Present or Last Employer:
Name
Position Held
Address

(street) (City)(State/Zip)

Reason For Leaving
Phone #

Were you subject to the FMCSRs* while employed here ?

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 ?

Mo/Yr
From
Mo/Yr
To
Present or Last Employer:
Name
Position Held
Address

(street) (City)(State/Zip)

Reason For Leaving
Phone #

Were you subject to the FMCSRs* while employed here ?

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 ?

Mo/Yr
From
Mo/Yr
To
Present or Last Employer:
Name
Position Held
Address

(street) (City)(State/Zip)

Reason For Leaving
Phone #

Were you subject to the FMCSRs* while employed here ?

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 ?

*The Federal Motor Carrier Safety Regulations (FMCSRs) apply to anyone who operates a motor vehicle on 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 Experience

Class of Equiement Dates
FromTo 		Approximate Number of Miles (Total)
Straight Truck
Tractor and Semi-trailer
Tractor-two trailers
Tractor-three trailers (triples)
Other
List states operated in, for the last five years:
List special courses/training competed (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 Accident Nature of Accidents (Head on, rear end, upset, etc.) Location of Accident # of
Fatalities 		# of People
Injured

Traffic Convictions and Forfeitures for the last three years(other than parking violations)

Date Location Charge Penalty

Driver's License (list each driver's license held in the past three years)

State License # Type Endorsements Expiration Date

A. Have you ever been denied a license, permit or privilege to operate a motor vehicle?..

B. Has any license, permit or privilege ever been suspended or revoked?

C. 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)?

D. Have you ever been convicted of a felony*?

If the answers to A, B, C or D is "YES", give details

* Disclosure of this information does not automatically exclude the driver from consideration

To Be Read and Signed by Driver

It is agreed and understood that any misrepresentation given on this document shall be considered an act of dishonesty.

It is agreed and understood that the motor carrier or his agents may investigate my background to ascertain any and all information of concern to commercial driving record, whether same is of record or not, And I release the employers and persons named herein from all liability for any damages on account of their 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.

This certifies that the above information was completed by me, and that all entries on it and information in it are true and complete to the best of my knowledge.

Digital Signature (Type Full Name)
Date

Great West Casualty Company does not provide legal advice to its customers, nor does it advise insureds on employment related issues, therefore the subject matter is not intended to serve as legal or employment advice for any issue(s) that may arise in the operations of its insureds. Legal advice should always be sought from the insured's legal counsel. Great West Casualty Company shall have neither liability nor responsibility to any person or entity with respect to any loss, action Or inaction alleged to be caused directly or indirectly as a result of the information contained herein.

Request for Driver's Safety Performance History
Information from DOT Regulated Previous Employer(s)

Carrier Name:
Contact Person:
Address:
City, State, Zip:
Phone #:
Confidential Fax #:

Driver to Complete This Section

As a Commercial Motor Vehicle (CMV) Driver, I understand that per, the Federal Motor Carrier Safety Regulations (FMCSRs) Part 391, 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 and 391 Subpart G, 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.

I understand should I refuse to provide the written consent requested, the prospective motor carrier employer shall not permit me to operate a commercial motor vehicle for that motor carrier per FMCSA 391.23(f).

I , hereby authorize this company to release all records of employment, including assessments

Print Name

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 company from the dates of To

Applicant's Signature
SSN or ID Number
D.O.B.
Today's Date

SECTION I — Past Employer to Complete >> DRUG & ALCOHOL INFORMATION

Please provide the following drug and alcohol information, as required by FMCSR Part 391.23(e) and 40_25. If no drug and alcohol information is available on above-named applicant, check here. ❑

YES

NO

1. Within the previous three (3) years, has the driver had violated any of the alcohol and controlled substance prohibitions under FMCSR 382, Subpart B, or 49 CFR 40?
2. If the answer to number one is "yes", did the driver fail to undertake or complete a rehabilitation program prescribed by a substance abuse professional (SAP) pursuant to FMCSR 382.605, or 45 CFR 40, Subpart 0?
3. If the answer to number two is "yes", if the driver successfully completed the SAP rehabilitation referral and remained in your employment, did the driver have any of the following testing violations subsequent to the completion of the rehabilitation program described above?
(i) Any alcohol test with a result of 0.04 or higher alcohol concentration?
(ii) Any verified positive drug test?
(iii) Any refusals to be tested (including verified adulterated or substituted drug test results)?
4. Any other violations of DOT agency drug and alcohol testing regulations (Part 382 or Part 40)?
5. If yes to any of the above questions, please provide documentation of successful completion of a SAP evaluation, prescribed treatment and return-to-duty requirements (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,

SECTION II — Past Employer to Complete >> ACCIDENT INFORMATION

Please provide the following information as required by 391.23(d) (1) (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.❑

Date Location
(Please give city/town, or most near and state)		 Any Vehicle
Towed		 HazMat..
Spill		 # of
Fatalities		 # of
Injuries

SECTION III — Past Employer to Complete >> WORK HISTORY INFORMATION

Please provide the following information on the above-name driver/applicant;

He/She was employed for you as a : from To

  • If employed as a driver, what type of equipment did he/she operate?

    Explain:
    Type of trailer(s) pulled:
    Was he /she a: Company Driver?
    Contractor?
    Contractor's Driver?
    Other?
    General area traveled:
    Commodities transport:

  • While under your employment was he/she:

    • a. Bonded:
    • b. Convicted of any traffic violations:
      If yes, please list all, including date and type:
    • c. License(s) suspended, revoked or denied:
      If yes, please explain:

  • Reason for leaving:

  • Would you re-employ this person:
    Please explain:

Additional Comments:

Previous Employer Representative Supplying Information:

Print Name

Title

Signature

Date

Please remember to retain a copy for your records; your timely response is appreciated

Great West Casualty Company does not provide legal advice to its customers, nor does it advise insureds on employment related issues, therefore the subject matter is not intended to serve as legal or employment advice for any issue(s) that may arise in the operations of its insureds. Legal advice should always be sought from the insured 's legal counsel. Great West Casualty Company shall have neither liability nor responsibility to any person or entity with respect to any loss, action or inaction alleged to be caused directly or indirectly as a result of the information contained herein.

DRIVER'S RIGHTS PERTAINING TO RELEASE OF DRIVER INFORMATION UNDER REGULATION 391.23

Motor carriers have the responsibility 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 a continuous period which began before January 1, 1971.

  • (a)(1) 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 date 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:

  1. The right to review information provided by previous employers.
  2. 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.
  3. 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.

Drivers 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 within 15 days of receiving the driver's 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 Signature:
Date
Driver Name (Printed)
Great West Casualty Company does not provide legal advice to its customers, nor does it advise insureds on employment related issues, therefore the subject matter is not intended to serve as legal or employment advice for any issue(s) that may arise in the operations of its insureds. Legal advice should always be sought from the insured's legal counsel. Great West Casualty Company shall have neither liability nor responsibility to any person or entity with respect to any loss, action or inaction alleged to be caused directly or indirectly as a result of the information contained herein.

THE BELOW DISCLOSURE AND AUTHORIZATION LANGUAGE IS FOR MANDATORY USE BY ALL ACCOUNT HOLDERS

IMPORTANT DISCLOSURE REGARDING BACKGROUND REPORTS FROM THE PSP Online Service

In connection with your application for employment with K & S CARRIERS, LLC ("Prospective Employer"), Prospective Employer, 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 final 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; that the 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.

Neither the Prospective Employer nor the FMCSA contractor supplying the crash and safety information has the capability to correct any safety data that appears to be incorrect. You may challenge the accuracy of the data by submitting a request to https://dataqs.fmcsa.dot.gov. if you challenge crash or inspection information reported by a State, FMCSA cannot change or correct this data. Your request will be forwarded by the DataQs system to the appropriate State for adjudication.

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 Federal Motor Carrier Safety Regulations (FMCSR) violations that have been adjudicated by a court of law will also appear, and remain, on a PSP report.

The Prospective Employer cannot obtain background reports from FMCSA without your authorization.

AUTHORIZATION

If you agree that the Prospective Employer may obtain such background reports, please read the following and sign below:

I authorize K & S CARRIERS, LLC ("Prospective Employer") 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 authorizing 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.

I further understand that neither the Prospective Employer nor 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 challenge crash or inspection information reported by a State, FMCSA cannot change or correct this data. I understand my request will he forwarded by the DataQs system to the appropriate State for adjudication.

understand that any crash or inspection in which I was involved will display on my PSP report. Since the PSP report does not report, or assign, or imply fault, I acknowledge it will include all CMV crashes where I was a driver or co-driver and where those crashes were reported to FMCSA, regardless of fault. Similarly, I understand all inspections, with or without violations, will appear on my PSP report, and State citations associated with FMCSR violations that have been adjudicated by a court of law will also appear, and remain, on my PSP report. I have read the above Disclosure Regarding Background Reports provided to me by Prospective Employer and I understand that if I sign this Disclosure and Authorization, 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:

signature


Name (Please Print)

NOTICE This form is made available to monthly account holders by N1C on behalf of the U.S Department of Transportation, Federal Motor Canter Safety Administration (FMCSA) Account holders are required by federal law to obtain an Applicant's written or electronic consent prior to accessing the Applicant's PSP report. Further, account holders are required by FMCSA to use the language contained in this Disclosure and Authorization form to obtain an Applicant's consent The language must be used in whole, exactly as provided Further, the language on this form must exist as one stand-alone document The language may NOT be included with other consent forms or any other language