OCEANSIDE RUBBISH, INC. P. O. Box 39 Wells, Maine 04090

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1 OCEANSIDE RUBBISH, INC. P. O. Box 39 Wells, Maine

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5 40.25(j) Pre-Employment Verification of Testing Results Company Name: Oceanside Rubbish, Inc. P O Box 39 Tel # Wells, Maine Fax# Applicant Name: Identification Number: In the past 2 years have you: YES NO Tested positive for any controlled substances pre-employment test for any other company? Refused to be tested for any controlled Substances pre-employment test for any other company? Tested above.04 on any Alcohol pre-employment test for any other company? If you answered yes to any of the above questions, can you document which Substance Abuse Professional (SAP) you consulted? Name of (SAP): Address: City, State, Zip: Telephone: Applicant s Signature Date: DQ FILE 5

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7 OCEANSIDE RUBBISH, INC. ALCOHOL AND CONTROLLED SUBSTANCE TESTING POLICY POSITIVE TEST RESULTS Please be aware that if you tested positive for marijuana on your pre-employment drug screening. We are unable to hire you on into a safety sensitive position as driver with these test results. Please note that this letter serves as instruction for you to seek the help of a Substance Abuse Professional (SAP) at your own expense. Only after receiving documentation of completion of a substance abuse program and a negative follow-up drug screen will you be permitted to be in a safety sensitive position of driver. Applicant s Signature Date 7

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9 OCEANSIDE RUBBISH, INC. I am applying to Oceanside Rubbish Inc. for a (Driver Laborer) position and agree to PAY UP FRONT to WORKWELL for a pre-employment lift evaluation and DOT Physical. If I pass these tests I will then (driver only) submit a pre- Employment Drug Screen paid for by Oceanside Rubbish, Inc. Pre-employment DOT Physical = $70.00 Drivers Pre-employment Lung Test = $53.00 Drivers Only if over 35 and Smoke Pre-employment Physical = $70.00 Laborers Pre-employment Lift Evaluation = $53.00 Drivers / Laborers Pre-employment Drug Screen = $50.00 Oceanside Rubbish, Inc. will reimburse those employees that complete three months of employment with the company for cost incurred for physicals. Any employee that is hired and does not complete the three month period will be charged back for any Preemployment expenses paid for by Oceanside Rubbish, Inc. in their final paycheck. By signing this form you are agreeing to the terms set forth by Oceanside Rubbish, Inc. Applicant s Signature APPOINTMENT DATE APPOINTMENT TIME PLEASE BRING YOUR LICENSE ALONG WITH PAYMENT OF $ TO, WORKWELL Second Floor One Medical Ctr. Dr. Biddeford, Maine DRIVERS PAY UP TO $ UP FRONT LABORERS PAY $ UP FRONT 9

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11 REQUEST FOR DRIVING RECORD NOTE TO MOTOR CARRIER: SEE BACK SIDE FOR STATES THAT ACCEPT THIS FORM I hereby authorize you to release the following information to OCEANSIDE RUBBISH, INC. (Prospective Employer) for purposes of investigation as required by sections and of the Federal Motor Carrier Safety Regulations. You are released from any and all liability which may result form furnishing such information. (Applicant's Signature) (Date) In accordance with the provisions of Section 604 and 607 of the Fair Credit Reporting Act, Public Law , as amended by the Consumer Credit Reporting Act of 1996 (Title II, Subtitle D, Chapter 1, of Public Law ), I hereby certify the following: 1. The consumer (applicant) has authorized in writing the procurement of this report; 2. The consumer (applicant) has been informed in a separate written disclosure that a consumer report may be obtained for employment purposes. 3 The information requested below will be used for a "permissible purpose" (i.e., information for employment purposes) will be used for no other purpose; 4 The information being obtained will not be used in violation of any federal or state equal opportunity law or regulation; and 5 Before taking an adverse action based in whole or in part on the report the consumer (applicant) will receive a copy of the requested report and the summary of consumer rights as provided with the report by the consumer reporting agency. I also hereby certify that this report request and the above applicant's release notice meet the definition of "permissible uses" of state motor vehicle records under the provisions of the Driver's Privacy Protection Act of 1994 (Public Law , Title XXX, Section (a)). (Signature of Requester) (Date) TO: PAQUIN & CARROLL P O BOX 356 BIDDEFORD, MAINE DEAR SIR/MADAM: The following named person has made application with our company for the position of. In accordance with Section , Federal Department of Transportation Regulations, please furnish the undersigned with the applicant's driving record for the past three years. The following named person is employed with our company in the position of. In accordance with Section , Federal Department of Transportation Regulations, please furnish the undersigned with the employee's driving record for the past year. NAME OF APPLICANT/DRIVER ADDRESS (Number & Street) (City) (State) (Zip Code) Former Address (Number & Street) (City) (State) (Zip Code) Date of Birth: S.S.N.: License # REQUESTED BY OCEANSIDE RUBBISH. INC. DONNA M. COLEMAN P O BOX 39 OFFICE MANAGER WELLS, MAINE