GS Trucking

General Information

Name (first, middle, last)

Hire Date (office use only)

Address (street, city, state, zip code)

Phone Number

Date of Birth

Social Security Number

Are you legally authorized to work in the U.S.?

Yes No

Emergency Contact Name

Relation

Address

Phone Number

DRIVER LICENSE INFORMATION

Driver License Number

State

Type

Expiration Date

DRIVER EXPERIENCE

Type Of Equipment

From Date

To Date

Approx # of Mile

Type Of Equipment

From Date

To Date

Approx # of Mile

REQUIRED QUESTIONS

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 CMV or while driving a CMV?YesNo

Yes No

Have you ever been convicted of any serious crime?(Include any plea of “Guilty” or “No Contest” except for minor traffic violation)

Yes No

If you answered yes to any of the above 4 questions, you must attach a statement of explanation

TICKETS / ACCIDENTS/ ETC. *write N/A if there is nothing to report

Accident Record for Past 3 Years

Date

Description

# of Injuries / Fatalities

Date

Description

# of Injuries / Fatalities

Traffic Convictions & Forfeitures for Past 3 Years

Date

Location

Charges

Penalty

Date

Location

Charges

Penalty

EMPLOYMENT RECORD Applicant must include 10 years of any\all employment.Begin with your most recent employer and work back until 10 years are included

Employer

From (M/Y)

Reason For Leaving

Address

Phone

Position

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

From (M/Y)

Reason For Leaving

Address

Phone

Position

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

From (M/Y)

Reason For Leaving

Address

Phone

Position

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

From (M/Y)

Reason For Leaving

Address

Phone

Position

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

DECLARATION OF EMPLOYMENT STATUS (GAPS IN HISTORY) If you were driving a CMV, you must provide complete employment history for the past 10 years.

Any gaps in employment longer than 1 month are explained as follows:

Activity During Break

From (M/Y)

In Addition, I was not employed by any company or individual

Yes No

Activity During Break

From (M/Y)

In Addition, I was not employed by any company or individual

Yes No

Activity During Break

From (M/Y)

In Addition, I was not employed by any company or individual

Yes No

Employment History Continued

Employer

From (M/Y)

Reason For Leaving

Address

Phone

Position

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

From (M/Y)

Reason For Leaving

Address

Phone

Position

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

From (M/Y)

Reason For Leaving

Address

Phone

Position

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

From (M/Y)

Reason For Leaving

Address

Phone

Position

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

DECLARATION OF EMPLOYMENT STATUS (GAPS IN HISTORY) If you were driving a CMV, you must provide complete employment history for the past 10 years.

Any gaps in employment longer than 1 month are explained as follows:

Activity During Break

From (M/Y)

In Addition, I was not employed by any company or individual

Yes No

Activity During Break

From (M/Y)

In Addition, I was not employed by any company or individual

Yes No

Activity During Break

From (M/Y)

In Addition, I was not employed by any company or individual

Yes No

TO BE READ AND SIGNED BY APPLICANT

I authorize you, GS TRUCKING INC. , 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, as well as the FMCSRs.

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 391.23 (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

Print Name

Date

Witness Signature

Print Name

Date

ALCOHOL & CONTROLLED SUBSTANCE CONSENT AND RELEASE applicant MUST answer:

Have you ever failed a pre-employment drug test, and as a result not been hired for a DOT-regulated safety-sensitive position? (to include driving a CDL truck)

Yes No

Have you ever refused to be tested for drugs or alcohol when required by the DOT, including pre-employment?

Yes No

If you answered “Yes” to either of the above questions, can you provide evidence of having completed the return-to-duty process as described in part 40 of the DOT Regulations?

Yes No N\A

Note to employer: If a person has failed a drug or alcohol test, or refused to be tested, at any time since 1994, he/she is not eligible for employment in a safety-sensitive role unless they have completed the return to duty process.If a person answers “yes” to either of the 1st two questions and cannot provide evidence of completion of the RTD process, you have two options: do not hire, or do not hire until an initial SAP evaluation leading to a Return-to-Duty

I understand that, as required by the Federal Motor Carrier Safety Regulations and company policy, all CDL drivers must submit to alcohol and controlled substance testing as a condition of employment. Non-CDL drivers may also be subject to testing per company policy. I also understand any offer of employment will be contingent upon the results of an alcohol and controlled substance test

Applicants for positions that require driving a commercial motor vehicle (CMV) requiring a CDL at any time will be required to undergo controlled substances and at our discretion, alcohol testing prior to employment and will be subject to further testing throughout their period of employment.

The company’s policy is that if a person has ever been in violation of the rules in part 40 (DOT) or 382 (FMCSA) they will NOT be considered eligible for any job which includes operation of a CMV (Greater than 10,000 GVWR) unless they have completed the return to duty process.

CDL drivers will be subject to random and reasonable suspicion drug testing each day they report for work.

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)

This certify that I have read, understand, and agree to abide by the condition of this consent and release form. Failure to answer these questions and sign will prevent this employer from using you as a CMV operator.

Applicant Signature

Date

Print Name

Social Security Number

Employer Witness

Title

CERTIFICATION OF COMPLIANCE WITH DRIVER LICENSE REQUIREMENTS – PART 383

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, 1987. They are as follows:

You, as a commercial vehicle driver, may not possess more than one license.
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
Sections 392.42 and 383.33 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 383.31 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:

Driver License Number

State

Expiration Date

Employer Witness

Date

SAFETY PERFORMANCE HISTORY RECORDS REQUEST

Section 1 : To be Completed by Prospective Employee (APPLICANT)

I, (First, Middle, Last)

Social Security Number

Date of Birth

Hereby Authorize (My Previous Employer):

Address (Street)

Phone

Address (City, State, Zip)

FaxTo

To release and forward the information requested by sections 2 & 3of this document including my Alcohol and Controlled Substance Testingrecords within the previous 3 years from :(M/Y of employment dates)

From

To

To My Prospective Employer
GS TRUCKING INC.

Phone: 484-767-9703

Fax: 610-438-1941

Attn: Safety Manager

Address 38 ADAMSON STREET EASTON, PA 18042

In compliance with §40.25(g) and 391.23(h), release of this information must be made in a written form that ensures confidentiality, such as fax, letter, or e-mail

Applicant Signature

Date

General Consent for Limited Queries f the Federal Motor Carrier Safety Administration (FMCSA) Drug and Alcohol Clearinghouse

I, , hereby provide consent to (employer name) GS TRUCKING INC.to conduct a limited query of the FMCSA Commercial Driver’s License Drug and Alcohol Clearinghouse (Clearinghouse) to determine whether drug or alcohol violation information about me exists in the Clearinghouse

This shall include consent of initial inquiry, as well as annual queries (if applicable) required by FMCSA for the duration of my employment.

I understand that if a limited query conducted by(employer name) _GS TRUCKING INC. indicates that drug or alcohol violation information about me exists in theClearinghouse, FMCSA will not disclose that information to (employer name) _GS TRUCKING INC. obtaining additional specific consent from me

further understand that if I refuse to provide consent for (employer name) GS TRUCKING INC.without firstto conduct alimited query of the Clearinghouse, (employer name) GS TRUCKING INC. must prohibit me from performing safety-sensitive functions, including driving a commercial motor vehicle, as required by FMCSA’s drug and alcohol program regulations

Signature

Date

HOURS OF SERVICE RECORD (7 DAY SHEET)

FOR FIRST TIME OR INTERMITTENT DRIVERS

On the first day you drive, you must fill out this form to record all work from the previous week done for direct or indirectcompensation

Name

Employee ID#:

Location

Date

Total Time on Duty

Time Relieved from duty

(7 days ago)

(6 days ago)

(5 days ago)

(4 days ago)

(3 days ago)

(2 days ago)

(Yesterday)

(Today)

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

Signature

Date

Time

From

To

DRIVER HIRING ROAD TEST

PART A – TEST

Drivers Name

Phone Number

Address

City, State Zip

Rating of Performance

The pre-trip inspection (as required by Sec. 392.7)

Coupling and uncoupling of combination units, if the equipment he or she may driveincludes 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 in giving test

Use of vehicle’s controls and emergency equipment

Examiners Signature

Date

PART B - CERTIFICATION OF ROAD TEST

Driver’s Name

Social Security Number

License Number

State

Type of Power Unit

Type of Trailer

If a passenger carrier, type of bus

This is to certify that the above-named driver was given a road test under my supervision on (date) consisting of approximately miles of driving. It is my considered opinion that this driver possessed sufficient driving to operate safety in the type ofcommercial motor vehicle listed above.

Date

No Of Miles

Examiners Signature

Title

Organization & Address

ANNUAL REVIEW OF DRIVING RECORD

PART A – CERTIFICATION OF VIOLATIONS

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 391.27)

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

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’s license #:

State

Exp. Date

If you have moved in the last 12 months, provide your new address here

Change Address:

Driver Signature

Date

PART C – CARRIER’S ANNUAL REVIEW

Carrier’s annual review of driving record and certification of continued qualification as required by FMCSR 391.25(c)(2)This day I have reviewed the driving record of the above named driver in accordance with 391.25 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

Yes No

The driver is disqualified to drive a CMV pursuant to 391.15., or

Yes No

This driver is disqualified to drive a CMV pursuant to company policy

Yes No

Carrier’s Name
GS TRUCKING INC.

Carrier’s Address
38 ADAMSON STREET EASTON, PA 18042

Reviewed by:

Title

Date

GS Trucking DQ Application

Accident Record for Past 3 Years

Traffic Convictions & Forfeitures for Past 3 Years

Any gaps in employment longer than 1 month are explained as follows:

Any gaps in employment longer than 1 month are explained as follows:

FOR FIRST TIME OR INTERMITTENT DRIVERS

Rating of Performance