Driver Hiring Checklist

Transcription

1 Driver Hiring Checklist Driver Qualification File Driver Specific Application ( 5 Pages ) Release & Consent Form Consumer Reports Motor Vehicle Report Disclosure & Authorization to Release Information Motor Vehicle Record (MVR) ( Paymasters will do and send with complete file ) Certificate of Violations / Annual Review of Driving Record Road Test / Certificate Photocopy of CDL Front / Back Medical Examiners Certificate Medical Examiners National Registry Verification ( Paymasters will fill out and send with complete file ) Drug & Alcohol Records Other Folder Driver issued education materials and company drug testing policy Dot Pre-employment Drug Screen Result Documentation and Release of pre-employment testing information by driver / applicant Previous Employment Checks ( Have employee sign / date form Paymasters requests info from previous employer ) Communication ( For Paymasters use ) Checklist Statement of On Duty Hours I-9 Fair Credit Reporting Act Disclosure Commercial Driver Job Description Return To Work Statement Acknowledgment and Authorization for Co-Employment W4 Direct Deposit Form FMCSA Regulations Receipt New hire reporting ( Paymasters will take care of and send with completed file ) EEO-1 ( 2 pages includes Reasonable Accommodation Form) Work Opportunity Tax Credit form ( 5 pages- includes 8850 Form- last 2 pages are instructions ) PSP Disclosure and Authorization Form

2 APPLICATION FOR EMPLOYMENT (COMMERCIAL DRIVER) ALL POTENTIAL EMPLOYEES ARE EVALUATED WITHOUT REGARD TO RACE, COLOR, RELIGION, GENDER, NATIONAL ORIGIN, AGE, MARITAL OR VETERAN STATUS, THE PRESENCE OF A NON-JOB RELATED HANDICAP OR ANY OTHER LEGALLY PROTECTED STATUS. Raveill Trucking, Inc Hwy 210 McGregor, MN The purpose of this application is to determine whether or not the applicant is qualified to operate Motor Carrier s equipment according to the requirements of the Federal Motor Carrier Safety Regulations and the Client Company named above. Name _ Date Address City State Zip Home Phone_ Office Phone_ Other Phone_ Address: Social Security Number (Must have 3 years of address listed) Previous Address City State_ ZIP Previous Address City State_ ZIP 1. Position Sought: DRIVER 2. Date of Birth / / 3. Proof of Age 4. Height? ft_ in 5. Weight? lbs. 6. Are you employed now? [ ] Yes [ ] No 7. Have you worked for this company before? [ ] Yes [ ] No 8. If yes, for which client (Company) Dates worked From:_ /_ /_ To: /_ / Position Reason for Leaving Rate of Pay Are you a US citizen, or otherwise authorized to work in the U.S. without any restriction? [ ] Yes [ ] No Emergency Contact: Relationship Phone Number: ( ) - Work Number: ( ) - Other: ( ) - Are you physically capable of heavy, manual work? [ ] Yes [ ] No If no, please explain Do you have any physical condition which would limit your ability to perform the job applying for? [ ] Yes [ ] No In the past 3 years, have you lost any time from work? [ ] Yes [ ] No If yes, please explain Would you willing to take a physical examination? [ ] Yes [ ] No

3 EMPLOYMENT HISTORY ALL APPLICANTS WISHING TO DRIVER IN INTERSTATE COMMERCE MUST PROVIDE THE FOLLOWING INFORMATION ON ALL EMPLOYERS DURING THE PRECEDING THREE YEARS. YOU MUST GIVE THE SAME INFORMATION FOR ALL EMPLOYERS FOR WHOM YOU HAE DRIVEN A COMMERCIAL VEHICLE SEVEN YEARS PRIOR TO THE INITIAL THREE YEARS (TOTAL OF TEN YEAR EMPLOYMENT RECORD). Before an application is submitted, the motor carrier must inform the applicant that the information he/she provides in accordance with paragraph (b) (10) of this section may be used, and the applicant s previous employers will be contacted, for the purpose of investigating the applicant s safety performance history information as required by paragraphs (d) and (e) of YOUR ARE REQUIRED TO LIST THE COMPLETE MAILING ADDRESS: STREET NUMBER AND NAME, CITY, STATE AND ZIP CODE. (Most Recent First.) 1.Employer_ Position Address Dates Employed: From:_ To:_ City State Zip Phone Contact Person:_ Ending Salary Reason for Leaving Where you subject to the Federal Motor Carrier Safety Registration while employed? [ ] Yes [ ] No Was your job designated as safety sensitive function in any DOT-Regulated mode subject to drug and alcohol testing? [ ] Yes [ ] No 2.Employer_ Position Address Dates Employed: From:_ To:_ City State Zip Phone Contact Person:_ Ending Salary Reason for Leaving Where you subject to the Federal Motor Carrier Safety Registration while employed? [ ] Yes [ ] No Was your job designated as safety sensitive function in any DOT-Regulated mode subject to drug and alcohol testing? [ ] Yes [ ] No 3.Employer_ Position Address Dates Employed: From:_ To:_ City State Zip Phone Contact Person:_ Ending Salary Reason for Leaving Where you subject to the Federal Motor Carrier Safety Registration while employed? [ ] Yes [ ] No Was your job designated as safety sensitive function in any DOT-Regulated mode subject to drug and alcohol testing? [ ] Yes [ ] No 4.Employer_ Position Address Dates Employed: From:_ To:_ City State Zip_ Phone Contact Person:_ Ending Salary Reason for Leaving Where you subject to the Federal Motor Carrier Safety Registration while employed? [ ] Yes [ ] No Was your job designated as safety sensitive function in any DOT-Regulated mode subject to drug and alcohol testing? [ ] Yes [ ] No 5.Employer_ Position Address Dates Employed: From:_ To:_ City State Zip _Phone Contact Person:_ Ending Salary Reason for Leaving Where you subject to the Federal Motor Carrier Safety Registration while employed? [ ] Yes [ ] No Was your job designated as safety sensitive function in any DOT-Regulated mode subject to drug and alcohol testing? [ ] Yes [ ] No 6.Employer_ Position Address Dates Employed: From:_ To:_ City State Zip Phone _ Contact Person:_ Ending Salary Reason for Leaving Where you subject to the Federal Motor Carrier Safety Registration while employed? [ ] Yes [ ] No Was your job designated as safety sensitive function in any DOT-Regulated mode subject to drug and alcohol testing? [ ] Yes [ ] No

4 7.Employer_ Position Address Dates Employed: From:_ To:_ City State Zip Phone Contact Person:_ Ending Salary Reason for Leaving Where you subject to the Federal Motor Carrier Safety Registration while employed? [ ] Yes [ ] No Was your job designated as safety sensitive function in any DOT-Regulated mode subject to drug and alcohol testing? [ ] Yes [ ] No 8.Employer_ Position Address Dates Employed: From:_ To:_ City State Zip Phone Contact Person:_ Ending Salary Reason for Leaving Where you subject to the Federal Motor Carrier Safety Registration while employed? [ ] Yes [ ] No Was your job designated as safety sensitive function in any DOT-Regulated mode subject to drug and alcohol testing? [ ] Yes [ ] No 9.Employer_ Position Address Dates Employed: From:_ To:_ City State Zip Phone _Contact Person:_ Ending Salary Reason for Leaving Where you subject to the Federal Motor Carrier Safety Registration while employed? [ ] Yes [ ] No Was your job designated as safety sensitive function in any DOT-Regulated mode subject to drug and alcohol testing? [ ] Yes [ ] No 10.Employer_ Position Address Dates Employed: From:_ To:_ City State Zip Phone Contact Person:_ Ending Salary Reason for Leaving Where you subject to the Federal Motor Carrier Safety Registration while employed? [ ] Yes [ ] No Was your job designated as safety sensitive function in any DOT-Regulated mode subject to drug and alcohol testing? [ ] Yes [ ] No TO BE READ AND SIGNED BY APPLICANT I AUTHORIZE YOU 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 INTERVIEW(S) MAY RESLUT IN DISCHARGE. I UNDERSTAND, ALSO, THAT I AM REQUIRED TO ABIDE BY ALL RULES AND REGULATIONS OF THE COMPANY. I UNDERSTAND THAT INFORMATION I PROVIDE REGARDING CURRENT AND/OR PREVIOUS MAY BE USED, AND THOSE EMPLOYER(S) WILL BE CONTACTED, FOR THE PURPOSE OF INVESTIGATIONG MY SAFETY PERFORMANCE HISTORY AS REQUUIRED BY 49 CFR (d) AND (e). I UNDERSTAND THAT I HAVE THE RIGHT TO: REVIEW INFORMATION PROVIDED BY CURRENT/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. I ALSO UNDERTANT THAT MISREPRESENTATION OR OMISSION OF INFORMATION OR FACTS MAY RESULT IN MY REJECTION OR DISMISSAL. THIS CERTIFIES THAT THIS APPLCIATION WAS COMPLTED BY ME, AND THAT ALL ENTRIES ON IT AND INFORMAITON IN IT ARE TRUE AND COMPLETE TO THE BEST OF MY KNOWLEDGE. Applicant Signature Date IF THIS SECTION IS NOT SIGNED & DATED BY THE APPLICANT, THE APPLICATION WILL NOT BE PROCESSED. (i)(2) Drivers who have previous Department of Transportation regulated employment history in the preceding three years, and wish to review previous employer-provided investigative information must submit a written request to the prospective employer, which may be done at any time, including when applying, or as late as 30 days after being employed or being notified of denial of employment. The prospective employer must provide this information to the applicant within five (5) business days of receiving the written request. If the prospective employer has not yet received the requested information from the previous employer(s), then the five-business days deadline will begin when the prospective employer receives the requested safety performance history information. If the driver has not arranged to pick up or receive the requested records within thirty (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. Please contact Human Resources for more information

5 EXPERIENCE AND QUALIFICATIONS CLASS OF EQUIPMENT TYPE OF EQUIPMENT DATES APPROXIMATE NUMBER OF MILES (CIRCLE ALL THAT APPLY) FROM TO STRAIGHT TRUCK TRACTOR & SEMI-TRAILER TRACTOR TWO TRAILERS OTHER: VAN, REEFER, TANK, FLAT VAN, REEFER, TANK, FLAT VAN, REEFER, TANK, FLAT VAN, REEFER, TANK, FLAT List states operated in for the last 5 years Which safe driving awards do you hold and from who Show any special courses or training that will help you as a driver LICENSE INFORMATION SECTION FMCSR STATES NO PERSON WHO OPERATES A COMMERCIAL MOTOR VEHICLE SHALL AT ANY TIME HAVE MORE THAN ONE DRIVER S LICENSE. I CERTIFY THAT I DO NOT HAVE MORE THAN ONE MOTOR VEHICLE LICENSE, THE INFORMATION FOR WHICH IS LISTED BELOW. STATE LICENSE NUMBER EXPIRATION DATE A. Have you ever been denied a license, permit, or privilege to operate a motor vehicle? [ ] Yes [ ] No B. Have any license, permit, or privilege ever been suspended or revoked? [ ] Yes [ ] No If you answered Yes to any of these questions, attach a statement explaining the details If no accidents within the last 5 years, check here. [ ] ACCIDENT RECORD FOR PAST 5 YEARS OR MORE List most recent first. Attach sheet if more space is needed Date Nature of Accident Number of Number of Hazardous Material Spill (Month/ Year) (HEAD-ON, REAR-END, UPSET, ETC.) Fatalities Fatalities [ ] Yes [ ] Yes [ ] Yes [ ] Yes [ ] No [ ] No [ ] No [ ] No TRAFFIC CONVICTIONS & FORFEITURES FOR THE PAST 5 YEARS If no traffic convictions and/or forfeitures in the last 5 years, check here. [ ] Attach sheet if more space is needed Date Convicted Violation State of Violation Penalty (Month/Year) (Other than violations involving parking only) (Forfeited Bond, Collateral, and/or Points)

6 OTHER QUALIFICATIONS AND EXPERIENCE List courses and training other than shown elsewhere in this application. Show any trucking, or other experience that may help you in your work with this company. List any other special equipment or technical materials you can work with other than those already listed. I AUTHORIZE YOU 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 INTERVIEW(S) MAY RESLUT IN DISCHARGE. I UNDERSTAND, ALSO, THAT I AM REQUIRED TO ABIDE BY ALL RULES AND REGULATIONS OF THE COMPANY. Driver s Signature Date

7 COMMERCIAL DRIVER JOB FUNCTIONS The following are physical requirements pertaining to the job (s) for which you are applying. These bona fide physical requirements are essential functions of the job and are in addition to the skill, certification, years of experience and other qualifications required to perform the job (s) for which you have applied. Please be aware that all persons may be required to furnish health condition information and if necessary, submit to an examination by a company-designated physician. This information will be used to determine appropriate job placement. It shall not be used to disqualify an otherwise qualified person who may have a mental or physical disability who can perform these essential functions with or without reasonable accommodations. These statements / questions pertain only to the essential functions of the job for which you are applying. 1. Can you sit and drive as is required for an 11-hour shift? Yes No 2. Can you perform repetitive motion tasks with your hands and wrists? Yes No 3. Can you push and pull levers or objects that require 100 lbs. of force or more? Yes No 4. Do you have free and continual movement of your legs and feet as required to safely operate a clutch, brake and gas pedal or foot controls of a truck? Yes No 5. If required, are you able to reach and lift 60 lbs. above your head? Yes No 6. Can you climb stairs to safely get in and out of a truck or with a load regularly? Yes No 7. Can you grip, grasp and twist using your hands and wrists constantly as is required to safely operate the steering, shifting or other mechanical or hydraulic controls of a truck? Yes No 8. If required, are you able to lift and move 100 lbs. or more? Yes No 9. Is there any reason you may not be considered physically qualified to operate a commercial motor vehicle per the qualifications set forth in part of the Federal Motor Carrier Safety Regulations? Yes No For any No answers to questions 1-8 above, please explain below: Prompt and reliable attendance is a job requirement. I understand that any misstatement, omission, falsification, or misrepresentation of fact on this form is ground for withdrawal of the conditional job offer or termination of employment if already employed. Signature of Applicant Date Printed Name Social Security Number

8 Documentation and Release of pre-employment testing information by driver/applicant CFR 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 three 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 safetysensitive functions, until and unless the potential employee provides documentation of successful completion of the return -toduty process. (See Section 40.25(b)(5) and (e). Applicant Name: (Please Print) Social Security 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 three years? [ ] Yes [ ] No 2. If you answered yes, to the above question, can you provide proof that you have successfully completed the DOT return-to-duty requirements? [ ] Yes [ ] No If yes, please provide documentation of your successful completion of the return-to-duty process. My signature below certifies that the information provided is true and correct. Applicant Signature: Date:

9 REQUEST FOR INFORMATION FROM A PREVIOUS EMPLOYER I hereby authorize you, a DOT Regulated Employer for whom I have worked in the last 3 years, to release the following information to Paymasters for purposes of investigation as required by Sections 391 and 382 of the Federal Motor Carrier Safety Regulations. You are released from any and all liability which may result from furnishing such information. A SEPARATE FORM MUST BE SIGNED BY THE APPLICANT FOR EACH DOT REGULATED EMPLOYER FOR WHOM THE APPLICANT HAS WORKED IN THE LAST THREE (3) YEARS (FMCSR ). Date: Applicant s Signature Applicant s Printed Name: Previous Employer Name: Phone #: Fax #: The individual named below has applied to our company, or one of our client companies, for a position as a Commercial driver and states that he/she was employed by your company as a(n) from to. We appreciate your time in completing, in confidence, the information requested below. Please return form via fax to Or mail to Paymasters, PO Box 1567 Detroit Lakes, MN Any questions, please call Name of applicant: I SS#: 2. Employed from: to: as(n): 3. Did he/she drive a motor vehicle for you? Straight Truck Tractor Trailer Bus Other 4. If a tractor-trailer, what type of trailer? Dryvan Flatbed Reefer Hopper Dump Lowboy Tanker Container 5. Type of driving: Local Regional OTR I 6. Were DOT Logs Required to be kept? 7. Was he/she an on-time and dependable driver? Yes No 8. Was his/her overall work record satisfactory? Yes No 9. Reason for leaving your employ: Discharged; reason Resigned Layoff Military 10 Is he/she eligible for re-hire? Yes No If No, please explain 11. Please advise of any injuries, illnesses or prescribed medications: 12. Please advise of dates and details of any DOT reportable accidents or tickets (specify # of injuries, fatalities, property damage, hazardous spills, etc.): 13 Do you know of any reason why this person could not perform all the required duties of this position? 14. Comments regarding safety habits, awards, work ethics, skills, attitude, etc_: 15 In the past 3 years did he/she: test 0.04 or greater for alcohol? Yes No test positive for Controlled Substance? Yes No refuse to be tested while in your employ? Yes No violate any other Drug/Alcohol prohibitions? Yes No To your knowledge fail a drug or alcohol test for a previous employer? Yes No If YES to any of the above questions, please provide date test was failed or refused If YES to the above, did the driver follow the mandatory treatment steps? Yes No Person providing verification, please sign this form: SIGNATURE: TITLE: DATE:

10 CERTIFICATE OF VIOLATIONS I certify that the following is a true and complete list of traffic violations (other than parking tickets) for which I have been convicted or forfeited bond or collateral, during the past 12 months. 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 required to be listed according to Part of the Federal Motor Carrier Safety Regulations during the past 12 months. Driver s Printed Name Signature Date Raveill Trucking, Inc Hwy 210 McGregor, MN ANNUAL REVIEW OF DRIVING RECORD This day I reviewed the driving record of the above named driver in accordance with Part of the Federal Motor Carrier Safety Regulations. I considered any evidence that the driver has violated applicable provisions of the Federal Motor Carrier Safety Regulations. I considered the driver s accident record and any evidence that he/she has violated laws governing the operation of motor vehicles, and gave great weight to violations, such as speeding, reckless driving and operation under the influence of alcohol or drugs, that indicate the driver has exhibited a disregard for the safety of the public. Having done the above, I find that [ ] the driver meets the minimum requirements for safe driving, or [ ] the driver is disqualified to drive a motor vehicle pursuant to Raveill Trucking, Inc Hwy 210 McGregor, MN Supervisor s Printed Name Supervisor s Signature Date

11 FAIR CREDIT REPORTING ACT DISCLOSURE STATEMENT In accordance with the provisions of Section 604(b)(2)(A) of the Fair Credit Reporting Act, Public Law , as amended by the Consumer Credit Reporting Act of 1996 (Title II, Subtitle D, Chapter I, of Public Law ), you are being informed that reports verifying your previous employment, previous drug and alcohol test results, and your driving record may be obtained on you for employment purposes. These reports are required by Sections , , and of the Federal Motor Carrier Safety Regulations. Driver s Signature Date Print Name Social Security Number Driver s License Information Driver s License # Issuing State Expiration Date of License Date of Birth

12 Return To Work Statement Paymasters, Inc. believes employees are the most important assets of our company. We are committed to assisting our injured employee s return to work as soon as medically appropriate and to work with the medical community to help the injured employees regain their livelihood. The focus of our Return to Work (RTW) program is to meet the needs of both Paymasters, Inc. and our injured employees by modifying the employee s existing position and/or work schedule. The first option for transitional work is always the worksite employer. However, there are instances when that is not possible. In that case, Paymasters, Inc. will work at coordinating other transitional assignments within the same community as the worksite employer or within reasonable distance of the injured employee s place of residence. For this program to be successful the injured employee must report all injuries to Paymasters, Inc. Human Resources Department on the same day of the incident. We will provide our injured employees with information about our RTW program and other materials that can be presented to the treating medical provider so a temporary transitional duty assignment can be designed as soon as possible. Everyone should be alert for potential accidents and strive to eliminate them. If you are aware of an unsafe condition, it should be reported immediately to your supervisor to be addressed. This action may prevent an injury from occurring. If an injury does occur, it must be reported immediately to a supervisor whether or not you plan to seek immediate medical attention for the injury. Thank you and please remember most injuries can be prevented. I have read and agree to participate in the RTW program if I am involved in an on the job injury that prevents me from working my regular duties. Employee Signature: Date:

13 ACKNOWLEDGMENT AND AUTHORIZATION FOR CO-EMPLOYMENT I certify that answers given herein are true and complete to the best of my knowledge. Paymasters, Inc. is proud to have entered into a co-employer relationship with our Client (hereafter referred to as worksite employer ). With the co-employer relationship, Paymasters, Inc. and the worksite employer divide the employer responsibilities through our subscriber agreement. Paymasters, Inc. becomes the employer of record for payroll tax purposes, filing paperwork, administration of payroll, employee benefits, personnel systems and records. While the worksite employer continues to direct the employees day-to-day activities. All references to Company are intended to include both Paymasters, Inc. and the worksite employer. I authorize the Company to investigate all statements contained in this application for employment as may be necessary in arriving at an employment decision. I further agree to indemnify the Company against any and all liability that may result from making such investigation. I hereby understand and acknowledge that, unless otherwise defined by applicable law, any employment relationship with this organization is of an at will nature, which means that the Employee may resign at any time and the Employer may discharge Employee at any time with or without cause. It is further understood that this at will employment relationship may not be changed by any written document or by conduct unless such change is specifically acknowledged in writing by an authorized executive of this organization. I also acknowledge and understand that I am applying for employment with the Company, that if hired I will be an employee of the Company, and as a condition of my employment with the Company, the Company has the right to transfer my services to any available position, therefore, I agree to participate in any training that may be necessary to satisfy the position. I further agree that I will abide by all the rules, regulations and policies of the Company. and that failure to do so may be cause for termination. I further agree that in the event I am advanced any money by the Company. or any of its subscribers, and fail to make payment as agreed, the Company may deduct the amount unpaid from any wage I may have coming. In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the employer. Client: Applicant Signature: Date: Print Name:

14 THIS IS OPTIONAL Direct Deposit Authorization Form *Please note that it is not necessary to fill out a form if you have done so in the past, unless you are requesting a change of account information or you are requesting to cancel your direct deposit agreement. You are not required to submit a new form each plan year. Social Security Number or Employee I.D. Number: Last Name: First Name: Street Address: City: State: Zip Code: Daytime Phone Number and Extension: Address: Bank Name Bank Address Bank City State Zip Bank Phone Number Please indicate the type of agreement being authorized by placing an x next to the appropriate field: Nine Digit Routing Number (ABA Number) New Authorization Change of Account Information Cancel Authorization Account Number Type of Account Checking Savings I wish to receive my payments by Direct Deposit and, by including my address, I acknowledge that all correspondence regarding account balances and reimbursements will be made electronically. I hereby authorize Paymasters, Inc. to originate electronic credit transactions to my bank (or credit union or savings & loan) account indicated below and to credit the same to such account. If necessary, Paymasters, Inc. may make deductions from my account for any payments credited to my account in error. This authority is to remain in full force and effect until Paymasters, Inc. has received written notification from me of its termination in such time as to afford Paymasters, Inc. and my bank a reasonable opportunity to act. I understand that claims submitted with change will be delayed two business days while Paymasters, Inc. completes a zero dollar transaction with my financial institution to confirm the validity of this account. I understand that by participating in direct deposit, I will not receive my pay stubs in paper form. My pay stubs will be available electronically via PMI Online (WEBPAGE). I will be able to access my pay stubs through my worksite employers computer, public computer, or my personal computer by logging on to Paymasters, Inc s. 24 hour, convenient, and secure website using my personalized log in and password. Signature Date Please attach a copy of a voided check. Please do not send a deposit slip as sometimes the routing numbers are different from that of your checks. (Please include a copy of your voided check in the space below)

15 RELEASE & CONSENT FORM CONSUMER REPORTS HireRight PART 1 - DOT DRUG AND ALCOHOL RELEASE I authorize, per 49 CFR Part 40, the release of information from my DOT regulated drug and alcohol testing records by my previous employers to HireRight for the sale purpose of transmitting such records to PAYMASTERS and its representatives/agents/clients. I authorize the release of the following information concerning DOT drug and alcohol testing violations including pre-employment tests during the past three years: (l) alcohol tests with a result of 0.04 or higher; (ii) verified positive drug tests; (iii) refusals to be tested (including verified adulterated or substituted results); (iv) other violations of DOT drug and alcohol testing regulations; (v) information obtained from previous employers of drug and alcohol rule violation(s); and (vi) documents, if any, of completion of return-to-duty process following a rule violation. I hereby authorize my worksite employer to submit copies of my current and future drug test results to PAYMASTERS. This authorization shall expire if and when my worksite employer is no longer a client of PAYMASTERS. The information I have authorized HireRight to review involves tests required by the DOT. If any carrier/company/school for whom I was previously employed furnishes HireRight with information concerning items (i) through (vi) above, I also authorize that carrier/company/school to release and furnish the dates of my negative drug and/or alcohol tests with results below 0.04 during the three year period and the name and phone number of any substance abuse professionals who evaluated me during the past three years. PART 2 - CONSUMER REPORT DISCLOSURE AND RELEASE In connection with your employment or application for employment (including contract for services), consumer reports may be requested from HireRight or other Consumer Reporting Agencies ("CRA"). These reports may include the following types of information: names and dates of previous employers, reason for termination of employment, credit reports work experience, accidents, academic history, professional credentials, and drug/alcohol use. Such reports may contain public record information concerning your driving record, workers' compensation claims, credit, bankruptcy proceedings, criminal records, etc. from federal, state and other agencies which maintain such records; as well as information from CRA concerning previous driving record requests made by others from such state agencies and state provided driving records. If final adverse action is taken against you based upon a background report, PAYMASTERS will notify you that the action has been taken and that the background report was the reason for the action. I authorize PAYMASTERS to contact any organization or individual that I have listed on my employment application or resume or mentioned in job interviews and obtain from them any relevant information about my job qualifications, including my experience, skills and abilities. 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, as well as any reference- related information about me held or known by my former employers, supervisors, and co-workers. In addition I consent to the release of any information about my education, experience, abilities, or work-related characteristics or traits held or known by other organizations or individuals, including schools and educational institutions, professional or business associates, and friends and acquaintances that PAYMASTERS might contact in the course of conducting a reference check or background investigation of my suitability for employment. You have the right to make a request to CRA, upon proper identification, to request the nature and substance of all information in its files on you at the time of your request, including the sources of information and the recipients of any reports on you that CRA previously furnished within the three-year period preceding your request. PAYMASTERS can be contacted by mail at PO Box 1567 Detroit Lakes, MN or by phone at Information about Hire Right's privacy practices is available at I AUTHORIZE, WITHOUT RESERVATION, ANY PARTY OR AGENCY CONTRACTED BY CRA, TO FURNISH THE ABOVE-MENTIONED INFORMATION. THIS AUTHORIZATION DOES NOT APPLY TO DRUG AND ALCOHOL INFORMATION OBTAINED UNDER PART 1. I hereby consent to your obtaining the above information from CRA, and I agree that such information which CRA has or obtains, and my employment history (not Drug and Alcohol information without a specific consent from me) with you if I am hired, will be supplied by CRA to other companies which subscribe to CRA. I hereby authorize procurement of consumer report(s). If hired or contracted this authorization, for Part 2 reports only, shall remain on file and shall serves as ongoing authorization for you to procure consumer reports at any time during my employment or contract period. I understand and acknowledge that this release of information can involve my qualifications, performance, credentials, or other characteristics or factors affecting my suitability for employment with PAYMASTERS. Specifically, I am authorizing the release of any information about my performance, experience, capability, attitude, specific events, or other workrelated characteristics that currently are in the possession of the requested organizations or their managers or representatives. In exchange for PAYMASTERS's consideration of my employment application, I agree not to file or pursue any complaints, claims; or legal actions of any kind against any organization or individual that provides work-related information about me to PAYMASTERS or its agents in accordance with the terms and intent of this release. I also agree not to file or pursue any complaints, claims, or legal actions against PAYMASTERS or any of its employees, representatives, or agents arising out of their efforts to obtain work-related information about me. I have read the above Consumer Report Disclosure and Release provided to me by PAYMASTERS and I understand that if I sign this consent form, PAYMASTERS and l/ or any entity it retains to obtain such background reports may obtain reports of my credit, driving, and/or criminal background history in addition to information regarding my background, references, education, specific events, and past employment. I hereby authorize PAYMASTERS, its employees, agents, and affiliates to obtain the information authorized above. Applicant Signature: Date Applicant Name (Printed):

16 Motor Vehicle Report Disclosure & Authorization To Release Information I am aware that a consumer report, (motor vehicle record) will be obtained on me in the course of consideration for employment and at times throughout my employment. I hereby authorize, without reservation, any party, state, or agency contracted by to furnish the above mentioned information., I hereby authorize procurement of consumer report(s), If hired (or contracted) this authorization shall remain on file and serve as ongoing authorization for you to procure consumer reports at any time during my employment (or contract) period. First Name: Middle Name: Last Name: Address (No PO Box): City: State, Zip Social Security #: /_ /_ Date of Birth: /_ / Driver License #: State Driver s License Issue: Signature: Date:

17 DRIVER S RECEIPT FEDERAL MOTOR CARRIER SAFETY REGULATIONS I hereby acknowledge that I have received a copy of the Federal Motor Carrier Safety Regulations, 49 CFR parts 40 and 382, 383 and of the Department of Transportation. I agree to familiarize myself with these regulations and to comply with all the provisions of these regulations. I will also follow all company procedures as required by the Motor Carrier. Name of Driver Driver s Signature_ Name of Motor Carrier Raveill Trucking, Inc. Signature of Motor Carrier Date

18 DF - 6 DRIVER STATEMENT OF ON-DUTY HOURS (For Newly Hired Drivers) INSTRUCTION: Motor carriers when using a driver for the first time shall obtain from the driver a signed statement giving the total time on-duty during the immediately preceding 7 days and time at which such driver was last relieved from duty prior to beginning work for such carrier. Rule 395.8(j)(2) Federal Motor Carrier Safety Regulations. NOTE: Hours for any compensated work during the preceding 7 days, including work for a non-motor carrier entity, must be recorded on this form. Driver Name (Print) Social Security Number Driver s License: State Number Class Endorsement(s) Restriction(s) Type of License Issuing State DAY DATE 1 (yesterday) HOURS WORKED TOTAL HOURS I hereby certify that the information given above is correct to the best of my knowledge and belief, and that I was last relieved from work at A.M. P.M. On Time Day Month Year Driver s Signature Date DRIVER CERTIFICATION FOR OTHER COMPENSATED WORK INSTRUCTIONS: When employed by a motor carrier, a driver must report to the carrier all on-duty time including time working for other employers. The definition of on-duty time found in Section paragraphs (8) and (9) of the Federal Motor Carrier Safety Regulations includes time performing any other work in the capacity of, or in the employ or service of, a common, contract or private motor carrier, also performing any compensated work for any nonmotor carrier entity. (check one) Are you currently working for another employer? Yes No At this time do you intend to work for another employer while still employed by this company? Yes No I hereby certify that the information given above is true and I understand that once I become employed with this company, if I begin working for any additional employer(s) for compensation that I must inform this company immediately of such employment activity. Driver s Signature Date Witness: Company Representative Date

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23 LISTS OF ACCEPTABLE DOCUMENTS All documents must be UNEXPIRED LIST A LIST B LIST C Documents that Establish Both Identity and Employment Authorization Employees may present one selection from List A or a combination of one selection from List B and one selection from List C. OR Documents that Establish Identity AND Documents that Establish Employment Authorization 1. U.S. Passport or U.S. Passport Card 2. Permanent Resident Card or Alien Registration Receipt Card (Form I-551) 3. Foreign passport that contains a temporary I-551 stamp or temporary I-551 printed notation on a machinereadable immigrant visa 4. Employment Authorization Document that contains a photograph (Form I-766) 5. For a nonimmigrant alien authorized to work for a specific employer because of his or her status: a. Foreign passport; and b. Form I-94 or Form I-94A that has the following: (1) The same name as the passport; and (2) An endorsement of the alien's nonimmigrant status as long as that period of endorsement has not yet expired and the proposed employment is not in conflict with any restrictions or limitations identified on the form. 6. Passport from the Federated States of Micronesia (FSM) or the Republic of the Marshall Islands (RMI) with Form I-94 or Form I-94A indicating nonimmigrant admission under the Compact of Free Association Between the United States and the FSM or RMI 1. Driver's license or ID card issued by a State or outlying possession of the United States provided it contains a photograph or information such as name, date of birth, gender, height, eye color, and address 2. ID card issued by federal, state or local government agencies or entities, provided it contains a photograph or information such as name, date of birth, gender, height, eye color, and address 3. School ID card with a photograph 4. Voter's registration card 5. U.S. Military card or draft record 6. Military dependent's ID card 7. U.S. Coast Guard Merchant Mariner Card 8. Native American tribal document 9. Driver's license issued by a Canadian government authority For persons under age 18 who are unable to present a document listed above: 10. School record or report card 11. Clinic, doctor, or hospital record 12. Day-care or nursery school record 1. A Social Security Account Number card, unless the card includes one of the following restrictions: (1) NOT VALID FOR EMPLOYMENT (2) VALID FOR WORK ONLY WITH INS AUTHORIZATION (3) VALID FOR WORK ONLY WITH DHS AUTHORIZATION 2. Certification of Birth Abroad issued by the Department of State (Form FS-545) 3. Certification of Report of Birth issued by the Department of State (Form DS-1350) 4. Original or certified copy of birth certificate issued by a State, county, municipal authority, or territory of the United States bearing an official seal 5. Native American tribal document 6. U.S. Citizen ID Card (Form I-197) 7. Identification Card for Use of Resident Citizen in the United States (Form I-179) 8. Employment authorization document issued by the Department of Homeland Security Illustrations of many of these documents appear in Part 8 of the Handbook for Employers (M-274). Refer to Section 2 of the instructions, titled "Employer or Authorized Representative Review and Verification," for more information about acceptable receipts. Form I-9 03/08/13 N Page 9 of 9

24 DOT POLICY Federal Motor Carrier Safety Administration (FMCSA) DRUG AND ALCOHOL STATEMENT The format of this sample policy does not have to be followed as written, but your policy shall include all information listed in CFR Part (b) (1 11). For: Raveill Trucking, Inc. Herein referred to as (The Company) Purpose It is the policy of (The Company), that its drivers shall be free of substance abuse and alcohol abuse. The use of illegal drugs by drivers is prohibited. Furthermore, drivers shall not use alcohol or engage in prohibited conduct as defined herein. The overall goal of this policy is to promote a drug and alcohol-free transportation environment and to reduce accidents, injuries, and fatalities. Definitions Refer to CFR Part 382 for complete definitions Prohibitions: Commercial Motor Vehicle: A motor vehicle or combination of motor vehicles used in commerce to transport passengers or property if the vehicle 1. has a gross combination weight rate of greater than 26,001 pounds inclusive of a towed unit with a gross vehicle weight rating of more than 10,000 pounds or; has a gross vehicle weight rating of greater than 26,001 pounds, or; 2. is designed to transport 16 or more passengers, including the driver, or; 3. is of any size and used in the transportation of hazardous materials (see 49 U.S.C. 5103(b) and which require the motor vehicle to be placarded (see 49 CFR part 172, subpart F). Designated Employer Representative (DER): Individual identified by employer as able to receive communications and test results from service agents and who is authorized to take immediate action to remove employees from safety-sensitive duties and to make decisions in the testing and evaluation process. The individual shall be an employee of the company. Driver: Any person who operates a commercial motor vehicle. Includes, but is not limited to: full time, regularly employed drivers, casual, intermittent or occasional drivers, leased drivers and independent owner-operator contractors. Safety-Sensitive Function: all time from the time a driver begins to work or is required to be ready to work until the time he/she is relieved from work and all responsibility for performing work. Alcohol: 1. Drivers shall not report to/or remain on duty while having an alcohol concentration level of 0.04 or greater. 2. Drivers shall not use alcohol while performing safety-sensitive functions. 3. Drivers shall not use alcohol 4 hours prior to performing safety-sensitive functions. 4. Drivers shall not use alcohol for 8 hours following an accident or until he/she undergoes a postaccident alcohol test, whichever occurs first.

25 Controlled Substances: 1. Drivers shall not report or remain on duty when the driver uses any controlled substance, except in accordance with if a licensed medical practitioner has advised the driver that the substances will not effect his/her ability to safely operate a CMV. 2. Drivers shall not report, remain on duty or perform safety sensitive functions if he/she tests positive, has adulterated or substituted their specimen for controlled substances. Types of Tests Department of Transportation (DOT) requires six circumstances for drug and alcohol tests. They are (1) preemployment, (2) post-accident, (3) random, (4) reasonable suspicion, (5) return-to-duty, (6) follow-up. Refusal to Test 49 CFR Part 40, (40.261) No driver shall refuse to submit to either alcohol or controlled substances tests. Refusals to test are violations and shall require the same consequences as positive results. The following are examples of refusals to test: 1) Failure to appear within a reasonable amount of time from scheduled appointment (except in a pre-employment scenario) 2) Failure to remain at collection site 3) Failure to provide adequate amount of urine, breath or saliva and there is no valid medical explanation 4) Failure to undergo a medical examination when required to do so 5) Failure to sign Step 2 of the Alcohol Testing Form (ATF) 6) Failure to cooperate with any part of the testing process Consequences of Policy Violation Any driver who becomes unqualified or engages in prohibited conduct as set forth herein may be subject to termination of employment. Pre-Employment Testing All applicants for driving positions shall submit to urine drug tests. An applicant may not be required to submit to a urine drug test if: 1) (the Company) can verify that the driver has participated in a valid drug testing program within the preceding 30 days. 2) while participating in that program, the driver was either tested within the past 6 months or participated in a random selection program for the previous 12 months. (The Company) shall also verify that no prior employer of the driver has records indicating a violation of any DOT rule pertaining to controlled substance use within the previous 6 months. Random Testing (The Company) conducts random drug and alcohol testing. (The Company) or its agents shall submit all drivers to a random selection system. The random selection system provides an equal chance for each driver to be selected each time random selection occurs. Random selections shall be reasonably spread throughout the year. (The Company) shall select, at a minimum, 50 percent of driver positions in each calendar year. (The Company) shall select, at a minimum, 10 percent of the average number of driver positions for the random alcohol testing. Random selection, by its very nature, may result in driver s being selected in successive selection or more than once a calendar year. If a driver is selected at random, for either drug or alcohol testing, a (The Company) official shall notify the driver. Once notified, every action the driver takes shall lead to a collection. If the driver engages in conduct that does not lead to a collection as soon as possible after notification, such conduct may be considered refusal to a test. Post-Accident Testing When an accident involves a human fatality, surviving drivers shall submit to post-accident drug and alcohol testing. When a driver is involved in an accident that requires immediate medical treatment away from the scene or disabling damage to any motor vehicle requiring tow away AND is issued a citation, the driver shall submit to a drug and alcohol test.

26 The DOT requires that any time a post-accident drug or alcohol test is required, that it be performed as soon as possible following the accident. If no alcohol collection can be made within 8 hours, attempts to collect an alcohol sample shall cease. If no urine collection can be obtained for purposes of post-accident drug testing within 32 hours, attempts to make such collection shall cease. Reasonable Suspicion Testing Reasonable suspicion for requiring a driver to submit to drug and/or alcohol testing shall be deemed to exist when a driver manifests physical or behavioral symptoms or reactions commonly attributed to the use of controlled substances or alcohol. Such driver conduct shall be witnessed by at least one supervisor trained in compliance with CFR Prohibited Conduct The following shall be considered prohibited conduct for purposes of the policy: No driver shall report for duty or remain on duty while having breath alcohol concentration of.04 or greater. No driver shall be on duty or operate a commercial motor vehicle while the driver possesses alcohol unless the alcohol is manifested and transported as part of a shipment. No driver shall use alcohol while performing safety-sensitive functions, including driving, loading, unloading, maintaining or repairing a commercial motor vehicle, and seeking assistance or remaining in attendance with a disabled commercial motor vehicle. No driver required to take a post-accident alcohol test shall use alcohol for eight hours following the accident or until he/she undergoes a post-accident alcohol test, which ever occurs first. No driver shall refuse to submit to a post-accident, random, a reasonable suspicion, return-to-duty, or a follow-up breath alcohol or urine drug test. No driver shall report for duty or remain on duty when the driver uses any controlled substance, except when use is pursuant to the instruction of a physician who has advised the driver that the substance does not adversely affect the driver s ability to operate a motor vehicle. If (The Company) has actual knowledge or has reason to believe that a driver has engaged in prohibited conduct; (The Company) may require the driver to submit to drug and/or alcohol testing. If a driver engages in prohibited conduct, the driver is not qualified to drive a commercial motor vehicle and shall be immediately removed from service. (The Company) may in its discretion, at the request of the driver, keep the driver s position open while such driver attempts to become re-qualified. (The Company) may also take action against the employee up to and including termination. Substance Abuse Evaluation (The Company) shall provide a list of names, addresses and telephone numbers of qualified substance abuse professionals to employees (including new applicants) who violated DOT drug and alcohol regulations. If the driver desires to become re- qualified, the driver shall be evaluated by a Substance Abuse Professional (SAP) and submit to the SAPs recommendations which may include education and treatment, in order to become re-qualified. The driver shall submit to and successfully complete a return-to-duty drug and/or alcohol test. Such driver is also subject to follow-up testing. Follow-up testing is separate from and in addition to (The Company s) reasonable suspicion, postaccident, and random testing procedures. Follow-up testing shall be on a random basis and be in accordance with the instruction of the SAP. Follow-up testing may continue for a period of up to 60 months following the driver s return to duty. No fewer than 6 follow-up tests shall be performed in the first 12 months. The costs of the SAP evaluation, education and prescribed treatment shall be discussed with the driver and shall be a company decision based on benefits and union agreements. (The Company) does not guarantee or promise a position to the driver should he/she regain qualified status. Authorization for Previous Test Records (49 CFR 40.25) Within 30 days of performing a safety sensitive function, federal regulations require that (The Company) obtain certain drug and alcohol testing records from the driver s previous employers. The records of the past two years regarding drug and alcohol testing records as required to be provided to employers under federal regulation.

27 Urine Specimen for Controlled Substances Drug testing shall be performed on urine samples and shall be tested for the presence of drugs and/or metabolites of the following controlled substances: (1) marijuana, (2) cocaine, (3) opiates, (4) phencyclidine (PCP), and (5) amphetamine/methamphetamine. Collectors who have received formal training shall perform collections of urine specimens. Urine specimens shall be tested at a Substance Abuse and Mental Health Services Association (SAMHSA) certified laboratory. Specimens shall undergo a screening test, and if necessary, a confirmation test. Test results shall be reported by the laboratory to a Medical Review Officer (MRO) designated by (The Company). Pursuant to DOT regulations, individual test results for driver/applicants and drivers shall be released to (The Company) and shall be kept strictly confidential unless consent for the release of the test results has been obtained. Any individual who has submitted to drug testing in compliance with this policy is entitled to receive the results of such testing upon timely written request. An individual with verified positive test results shall be offered, by the MRO, the opportunity to have a portion of the original sample sent to a different SAMHSA-certified laboratory. The sample shall be tested for the presence of the controlled substance(s) found in the initial screening and confirmation testing procedures. The individual shall decide to have the split specimen tested within 72 hours of the initial notification of the positive result. (The Company) shall ensure that the test takes place even if the individual does not have the funds to pay for the test. (The Company) may elect to collect payment from the individual for the costs of the additional testing procedure. Alcohol Tests (The Company) shall perform initial alcohol tests using saliva or breath testing methods approved by the Department of Transportation. The driver shall follow all instructions given by the alcohol testing technician. In the event a driver tests positive on the initial test, he/she shall submit to a confirmation test performed on an approved evidential breath testing analyzer. If the confirmation result is 0.02 to 0.039, the driver shall be removed from duty for 24 hours or until his/her next scheduled on-duty time frame expires. Drivers with tests indicating an alcohol concentration 0.04 or higher are considered to have violated DOT regulations, shall be removed from safety-sensitive duties and shall be referred to a substance abuse professional (SAP). Random, post-accident and alcohol tests shall be performed just prior to, during, or just after duty. Return-to-duty tests shall be performed after the SAP has determined the employee has successfully complied with prescribed education and/or treatment. Training (The Company) shall ensure supervisors designated to determine whether reasonable suspicion exists to require a driver to undergo testing, receive at least 60 minutes of training on alcohol misuse and at least 60 minutes of training on controlled substances use. The training shall cover the physical, behavioral, speech, and performance indicators of alcohol misuse and use of controlled substances. (The Company) shall provide educational material that explains the requirements of , consequences of violating the regulations, and the employer s policies and procedures with respect to meeting these requirements. (The Company) shall ensure each driver is required to sign a statement certifying that he or she has received a copy of these materials described in CFR The policy is not intended nor should it be construed as a contract between (The Company) and the employee. This policy may be changed at any time at the sole discretion of (The Company). If you have any questions concerning the information please contact. Name and phone number of person responsible for (The Company) Alcohol & Controlled Substance Testing Program

28 I,, verify that I have read and understand the Alcohol and Controlled Substance Testing Program policy and that I have received a copy of it for my reference. (Name and signature of driver) (date) (Company representative) (date) Name of Company: Raveill Trucking, Inc.

29 Motor Carrier s MEDICAL EXAMINER S NATIONAL REGISTRY VERIFICATION Motor Carrier Instructions: The requirement to include verification of the medical examiner s National Registry listing in the driver s qualification file was published in the Federal Register April 20, Beginning May 21, 2014, motor carriers must verify that the medical examiner who signed the driver s medical card is listed on the National Registry. This Requirement is prescribed in and Investigation and inquires. (m)(1) The motor carrier must obtain an original or copy of the medical examiner s certificate issued in accordance with , and any medical variance on which the certification is based, and, beginning on or after May 21, 2014, verify the driver was certified by a medical examiner listed on the National Registry of Certified Medical Examiners as of the date of issuance of the medical examiner s certificate, and place the records in the driver qualification file, before allowing the driver to operate a CMV. (391.23(m)(1)) General requirements for driver qualification files. (b)(9) A note relating to the verification of medical examiner listing on the National Registry of Certified Medical Examiners required by (m). (391.51(b)(9)) MOTOR CARRIER Verification: The following medical examiner has been verified as being listed on the National Registry of Certified Medical Examiners as of the date of issuance of the medical examiner s certificate for the named driver. Drivers Name: ID #: Medical Examiner: National Registry Number: Motor Carrier: Location: Verified By: Date:

30 New Hire EEO-1 Data Sheet Please complete this New Hire EEO-1 Data Sheet. It will supply us with information we need for federal reporting obligations. Please be advised that this information will be used and kept confidential, in accordance with applicable laws and regulations. This information will not be used as the basis for any adverse employment decision. Name Last First Middle Social Security # (last 4 digits) EEO-1 Self-Identification We are subject to certain government recordkeeping and reporting requirements for the administration of civil rights laws and regulations. To comply with these laws, we invite you to voluntarily self-identify your race or ethnicity. Submission of this information is voluntary and refusal to provide it will not subject you to any adverse treatment. The information obtained will be kept confidential and separate from personnel files. It may only be used in accordance with the provisions of applicable laws, executive orders, and regulations, including those requiring information to be summarized and reported to the federal government for civil rights enforcement. When reported, data will not identify any specific individual. Please check the EEO Identification Group that best applies to you: Hispanic or Latino: A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race. - OR - White (Not Hispanic or Latino): A person having origins in any of the original peoples of Europe, the Middle East, or North Africa. Black or African American (Not Hispanic or Latino): A person having origins in any of the black racial groups of Africa. Native Hawaiian or Other Pacific Islander (Not Hispanic or Latino): A person having origins in any of the peoples of Hawaii, Guam, Samoa, or other Pacific Islands. Asian (Not Hispanic or Latino): A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian Subcontinent, including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam. American Indian or Alaska Native (Not Hispanic or Latino): A person having origins in any of the original peoples of North and South America (including Central America), and who maintain tribal affiliation or community attachment. Two or More Races (Not Hispanic or Latino): All persons who identify with more than one of the above races, excluding those who identify themselves as Hispanic or Latino. Gender: Male Female Signature Date If you should have any questions regarding this form, please contact Human Resources. Revised

31 Form 8850 (Rev. March 2016) Department of the Treasury Internal Revenue Service Pre-Screening Notice and Certification Request for the Work Opportunity Credit Information about Form 8850 and its separate instructions is at Job applicant: Fill in the lines below and check any boxes that apply. Complete only this side. OMB No Your name Social security number Street address where you live City or town, state, and ZIP code County Telephone number If you are under age 40, enter your date of birth (month, day, year) 1 Check here if you received a conditional certification from the state workforce agency (SWA) or a participating local agency for the work opportunity credit. 2 Check here if any of the following statements apply to you. I am a member of a family that has received assistance from Temporary Assistance for Needy Families (TANF) for any 9 months during the past 18 months. I am a veteran and a member of a family that received Supplemental Nutrition Assistance Program (SNAP) benefits (food stamps) for at least a 3-month period during the past 15 months. I was referred here by a rehabilitation agency approved by the state, an employment network under the Ticket to Work program, or the Department of Veterans Affairs. I am at least age 18 but not age 40 or older and I am a member of a family that: a. Received SNAP benefits (food stamps) for the past 6 months; or b. Received SNAP benefits (food stamps) for at least 3 of the past 5 months, but is no longer eligible to receive them. During the past year, I was convicted of a felony or released from prison for a felony. I received supplemental security income (SSI) benefits for any month ending during the past 60 days. I am a veteran and I was unemployed for a period or periods totaling at least 4 weeks but less than 6 months during the past year. 3 Check here if you are a veteran and you were unemployed for a period or periods totaling at least 6 months during the past year. 4 Check here if you are a veteran entitled to compensation for a service-connected disability and you were discharged or released from active duty in the U.S. Armed Forces during the past year. 5 Check here if you are a veteran entitled to compensation for a service-connected disability and you were unemployed for a period or periods totaling at least 6 months during the past year. 6 Check here if you are a member of a family that: Received TANF payments for at least the past 18 months; or Received TANF payments for any 18 months beginning after August 5, 1997, and the earliest 18-month period beginning after August 5, 1997, ended during the past 2 years; or Stopped being eligible for TANF payments during the past 2 years because federal or state law limited the maximum time those payments could be made. 7 Check here if you are in a period of unemployment that is at least 27 consecutive weeks and for all or part of that period you received unemployment compensation. Signature All Applicants Must Sign Under penalties of perjury, I declare that I gave the above information to the employer on or before the day I was offered a job, and it is, to the best of my knowledge, true, correct, and complete. Job applicant s signature Date For Privacy Act and Paperwork Reduction Act Notice, see page 2. Cat. No L Form 8850 (Rev )

32 Form 8850 (Rev ) Page 2 For Employer s Use Only Employer s name Telephone no. EIN Street address City or town, state, and ZIP code Person to contact, if different from above Telephone no. Street address City or town, state, and ZIP code If, based on the individual s age and home address, he or she is a member of group 4 or 6 (as described under Members of Targeted Groups in the separate instructions), enter that group number (4 or 6) Date applicant: Gave information Was offered job Was hired Started job Under penalties of perjury, I declare that the applicant provided the information on this form on or before the day a job was offered to the applicant and that the information I have furnished is, to the best of my knowledge, true, correct, and complete. Based on the information the job applicant furnished on page 1, I believe the individual is a member of a targeted group. I hereby request a certification that the individual is a member of a targeted group. Employer s signature Title Date Privacy Act and Paperwork Reduction Act Notice Section references are to the Internal Revenue Code. Section 51(d)(13) permits a prospective employer to request the applicant to complete this form and give it to the prospective employer. The information will be used by the employer to complete the employer s federal tax return. Completion of this form is voluntary and may assist members of targeted groups in securing employment. Routine uses of this form include giving it to the state workforce agency (SWA), which will contact appropriate sources to confirm that the applicant is a member of a targeted group. This form may also be given to the Internal Revenue Service for administration of the Internal Revenue laws, to the Department of Justice for civil and criminal litigation, to the Department of Labor for oversight of the certifications performed by the SWA, and to cities, states, and the District of Columbia for use in administering their tax laws. We may also disclose this information to other countries under a tax treaty, to federal and state agencies to enforce federal nontax criminal laws, or to federal law enforcement and intelligence agencies to combat terrorism. You are not required to provide the information requested on a form that is subject to the Paperwork Reduction Act unless the form displays a valid OMB control number. Books or records relating to a form or its instructions must be retained as long as their contents may become material in the administration of any Internal Revenue law. Generally, tax returns and return information are confidential, as required by section The time needed to complete and file this form will vary depending on individual circumstances. The estimated average time is: Recordkeeping.. 6 hr., 27 min. Learning about the law or the form min. Preparing and sending this form to the SWA min. If you have comments concerning the accuracy of these time estimates or suggestions for making this form simpler, we would be happy to hear from you. You can send us comments from Click on More Information and then on Give us feedback. Or you can send your comments to: Internal Revenue Service Tax Forms and Publications 1111 Constitution Ave. NW, IR-6526 Washington, DC Do not send this form to this address. Instead, see When and Where To File in the separate instructions. Form 8850 (Rev )

33 U.S. Department Labor Employment and Training Administration 1. Control No. (For Agency use only) OMB No Expiration Date: November 30, 2016 Individual Characteristics Form (ICF) Work Opportunity Tax Credit 2. Date Received (For Agency Use only) APPLICANT INFORMATION (See instructions on reverse) EMPLOYER INFORMATION 3. Employer Name 4. Employer Address and Telephone 5. Employer Federal ID Number (EIN) APPLICANT INFORMATION 6. Applicant Name (Last, First, MI) 7. Social Security Number 8. Have you worked for this employer before? Yes No If YES, enter last date of employment: APPLICANT CHARACTERISTICS FOR WOTC TARGET GROUP CERTIFICATION 9. Employment Start Date 10. Starting Wage 11. Position 12. Are you at least age 16, but under age 40? Yes No If YES, enter your date of birth 13. Are you a Veteran of the U.S. Armed Forces? Yes No If NO, go to Box 14. If YES, are you a member of a family that received Supplemental Nutrition Assistance Program (SNAP) benefits (Food Stamps) for at least 3 months during the 15 months before you were hired? Yes No If YES, enter name of primary recipient and city and state where benefits were received. OR, are you a veteran entitled to compensation for a service-connected disability? Yes No If YES, were you discharged or released from active duty within a year before you were hired? Yes No OR, were you unemployed for a combined period of at least 6 months (whether or not consecutive) during the year before you were hired? Yes No 14. Are you a member of a family that received Supplemental Nutrition Assistance Program (SNAP) (formerly Food Stamps) benefits for the 6 months before you were hired? Yes No OR, received SNAP benefits for at least a 3-month period within the last 5 months But you are no longer receiving them? Yes No If YES to either question, enter name of primary recipient and city And state where benefits were received. 15. Were you referred to an employer by a Vocational Rehabilitation Agency approved by a State? Yes No OR, by an Employment Network under the Ticket to Work Program? Yes No OR, by the Department of Veterans Affairs? Yes No 16. Are you a member of a family that received TANF assistance for at least the last 18 months 1

34 before you were hired? OR, are you a member of a family that received TANF benefits for any 18 months beginning after August 5, 1997, and the earliest 18-month period beginning after August 5, 1997, ended within 2 years before you were hired? OR, did your family stop being eligible for TANF assistance within 2 years before you were hired because a Federal or state law limited the maximum time those payments could be made? If NO, are you a member of a family that received TANF assistance for any 9 months during the 18-month period before you were hired? If YES, to any question, enter name of primary recipient and the city and state where benefits were received. 17. Were you convicted of a felony or released from prison after a felony conviction during the year before you were hired? If YES, enter date of conviction and date of release. Was this a Federal or a State conviction? (Check one) Yes No Yes No Yes No Yes No Yes No 18. Do you live in an Empowerment Zone or Rural Renewal County (RRC)? Yes No 19. Do you live in an Empowerment Zone and are at least age 16, but not yet 18, on Yes No your hiring date? 20. Did you receive Supplemental Security Income (SSI) benefits for any month ending within 60 days before you were hired? Yes No 21. Are you a veteran unemployed for a combined period of at least 6 months (whether or not consecutive) during the year before you were hired? Yes No 22. Are you a veteran unemployed for a combined period of at least 4 weeks but less than 6 months (whether or not consecutive) during the year before you were hired? 23. Are you an individual who is or was in a period of unemployment that is at least 27 consecutive weeks the day before you began to work for the employer, or if earlier, the day you completed IRS Form Yes No 8850, the Prescreening Form? Yes No If YES, did you receive unemployment compensation/benefits under State or Federal law during a period of unemployment? Yes No 24. Sources used to document eligibility: (Employers/Consultants: List all documentation provided or forthcoming. For SWA Staff: List all documentation used in determining target group eligibility and enter your initials and date when the determination was made. I certify that this information is true and correct to the best of my knowledge. I understand that the information above may be subject to verification. 25(a). Signature: (See instructions in Box 25.(b) for who signs this signature block) 25.(b) Indicate with a mark who signed this form: Employer, Consultant, SWA, Participating Agency, Applicant, or 26. Date: Parent/Guardian (if applicant is a minor) ETA Form 9061 (Rev. May 2016) 2

35 INSTRUCTIONS FOR COMPLETING THE INDIVIDUAL CHARACTERISTICS FORM (ICF), ETA This form is used together with IRS Form 8850 to help state workforce agencies (SWAs) determine eligibility for the Work Opportunity Tax Credit (WOTC) Program. The form may be completed, on behalf of the applicant, by: 1) the employer or employer representative, the SWA, a participating agency, or 2) the applicant directly (if a minor, the parent or guardian must sign the form) and signed (Box 25a.) by the individual completing the form. This form is required to be used, without modification, by all employers (or their representatives) seeking WOTC certification. Simply complete, sign, and submit this form together with IRS Form 8850 to the SWA. For new hires that begin to work for an employer on or after January 1, 2015, and on or before May 31, 2016, this form can be completed, signed, and submitted together with IRS Form 8850 to the SWA by June 29, For new hires with an employment start date on or after June 1, 2016, employers must meet the 28-day timely filing requirement. The WOTC Employer Certification will be sent to you, if all statutory target group eligibility and timely filing requirements have been met. Boxes 1 and 2. SWA. For agency use only. Boxes 3-5. Boxes Employer Information. Enter the name, address including ZIP code, telephone number, and employer Federal ID number (EIN) of the employer requesting the certification for the WOTC. Do not enter information pertaining to the employer s representative, if any. Applicant Information. Enter the applicant s name and social security number as they appear on the applicant s social security card. In Box 8, indicate whether the applicant previously worked for the employer, and if Yes, enter the last date or approximate last date of employment. This information will help the 48-hour reviewer to, early in the verification process, eliminate requests for former employees and to issue denials to these type of requests, or certifications in the case of qualifying rehires during valid breaks in employment (see pages III-12 and III-13, Nov. 2002, Third Ed., ETA Handbook 408) during the first year of employment. Boxes Applicant Characteristics. Read questions carefully, answer each question, and provide additional information where requested. The Protecting Americans from Tax Hikes Act of 2015 retroactively reauthorized current target groups for a 5-year period, January 1, 2015 through December 31, 2019, and extended the Empowerment Zones designations for a two-year period, January 1, 2015 through December 31, The Act introduced a new target group, Qualified Long-term Unemployment Recipient (LTUR), for new hires that begin to work for an employer on or after January 1, 2016 December 31, 2019, see Box 23. For guidance see IRS Relief Period in TEGL No and IRS Notice Box 24 Sources to Document Eligibility. The applicant or employer is requested to provide documentary evidence to substantiate the YES answers in Boxes List or describe the documentary evidence that is attached to the ICF or that will be provided to the SWA. Indicate in parentheses next to each document listed whether it is attached (A) or forthcoming (F). Some examples of acceptable documentation are provided below. A letter from the agency that administers a program may be furnished specifically addressing the question to which the applicant answered YES. For example, if an applicant answers YES to either question in Box 14 and enters the name of the primary recipient and the city and state in which the benefits were received, the applicant could provide a letter from the appropriate SNAP (formerly Food Stamp) agency stating to whom SNAP benefits were paid, the months for which they were paid, and the names of the individuals included on the grant for each month. SWAs use this box to list the sources used to verify target group eligibility, followed with their initials and the date the determination was completed. Description of Examples of Documentary Evidence and Collateral Contacts. Employers/Consultants: You may check with your SWA to find out what other sources you can use to prove target group eligibility. (You are encouraged to provide copies of documentation or names of collateral contacts for each question for which you answered YES.) QUESTION 12 Birth Certificate or Copy of Hospital Record Driver s License School I.D. Card 1 Work Permit 1 Federal/State/Local Gov t I.D. 1 QUESTION 13 DD-214 or Discharge Papers Reserve Unit Contacts Letter of Separation or other agency documents issued only by the Department of Veterans Affairs (DVA) on DVA Letterhead certifying the Veteran has a service-connected disability and signed by the individual who verified this information. QUESTIONS 14 & 16 TANF/SNAP (Food Stamp) Benefit History or Case Number Identifier Signed statement from Authorized Individual with a specific description of the months benefits that were received QUESTION 15 Vocational Rehabilitation Agency Contact Veterans Administration for Disabled Veterans Signed letter of separation or related document from authorized Individual on DVA letter head or agency stamp with specific description of months benefits were received. For SWAs: To determine Ticket Holder (TH) eligibility, Fax page 1 of Form 8850 to MAXIMUS at: to verify if applicant: 1) is a TH, and 2) has an Individual Work Plan from an Employment Network. ETA Form 9061 (Rev. May 2016) 3

36 QUESTION 17 Parole Officer s Name or Statement Correction Institution Records Court Records Extracts QUESTION 18 & 19 To determine if a Designated Community Resident lives in a RRC, visit the site: Click on Find Zip Code; Enter & Submit Address/Zip Code; Click on Mailing Industry Information; Download and Print the Information, then compare the county of the address to the list in the January 2012 Instructions to IRS To determine if the DCR or a Summer Youth lives in an Empowerment Zone, check the most current instructions to IRS Form 8850, or visit the US. Department of Housing and Urban Development s locator at: QUESTION 20 SSI Record or Authorization SSI Contact Evidence of SSI Benefits QUESTIONS 21, 22 Unemployment Insurance (UI) Claims Records UI Wage Records QUESTION 23 UI Wage Records UI Claims Records Self-Attestation Form QUESTION 24 Employers/Representatives: List All sources used and provided to the SWA to document target group eligibility. SWA Staff: List all documentation used to determine/verify eligibility in the target group requested by the employer/rep., to reach the final determination. Notes: 1. Where a Federal/State/Local Gov t., School I.D. Card, or Work Permit does not contain age or birth date, another valid document must be obtained to verify an individual s age. 2. ESPL No , dated 3/18/98, officially rescinded the authority to use Form I-9 as proof of age and residence. Therefore, the I-9 is no longer a valid piece of documentary evidence. Box 25.(a) Signature. The person who completes the form signs the signature block. Box 25(b) Signature Options. (a) Employer or Authorized Representative, (b) SWA staff, (c) Participating Agency staff, or (d) Applicant (If applicant is a minor, the parent or guardian must sign). Box 26. Date. Enter the month, day and year when the form was completed. Persons are not required to respond to this collection of information unless it displays a currently valid OMB Control Number. Respondent s obligation to reply to these questions is required to obtain and retain benefits per law Public reporting burden for this collection of information is estimated to average 20 minutes per response including the time for reading instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing burden to the U.S. Department of Labor, Employment and Training Administration, Division of National Programs, Tools, and Technical Assistance, 200 Constitution Ave., NW, Room C-4510, Washington, D.C (Paperwork Reduction Project Control No ). ETA Form 9061 (Rev. May 2016) 4

37 ... (Cut along dotted line and keep in your files) TO: THE JOB APPLICANT OR EMPLOYEE, Privacy Act Statement: The Internal Revenue Code of 1986, Section 51, as amended and its enacting legislation, P.L , specify that the State Workforce Agencies are the "designated" agencies responsible for administering the WOTC certification procedures of this program. The information you have provided completing this form will be disclosed by your employer to the State Workforce Agency. Provision of this information is voluntary. However, the information is required for your employer to receive the federal tax credit. IF THE INFORMATION YOU PROVIDE IS ABOUT A MEMBER OF YOUR FAMILY, YOU SHOULD PROVIDE HIM/HER A COPY OF THIS NOTICE. ETA Form 9061 (Rev. May 2016) 5

38 U.S. Department Labor Employment and Training Administration OMB Control No Expiration Date: November 30, 2016 LONG-TERM UNEMPLOYMENT RECIPIENT SELF-ATTESTATION FORM Work Opportunity Tax Credit (WOTC) Program Instructions: This Self-Attestation Form (SAF) is to be completed, signed, and dated by the new hire only. Employers or consultants submit this SAF to the State Workforce Agency with IRS Form 8850 or if filed separately, with ETA Form 9061 (or ETA Form 9062) for each certification request filed for the new target group. Under penalties of perjury, I declare that this information is true and correct to the best of my knowledge. New Hire s Signature: Date New Hire Name: Social Security Number: - Date of Birth: (Enter last four digits) (Enter date) Employer Name: Employer Federal ID (EIN) Number: - (Enter last four digits) Please check all the statements that apply to you and provide all requested dates. Sign and date this form where indicated below. I declare that I was in a period of unemployment that is at least 27 consecutive weeks the day before I began to work for this employer, or, if earlier, the day I completed IRS Form I have been in a period of unemployment of not less than 27 consecutive weeks, from to. (Enter start date) (Enter end date) I make this declaration on the day I completed IRS Form (Enter date) I declare I have received unemployment compensation/benefits under State or Federal law during a period of unemployment. Privacy Act Notice: The Internal Revenue Code of 1986, Section 51, as amended and its enacting legislation, P.L , specify that the State Workforce Agencies are the "designated" agencies responsible for administering the WOTC certification procedures of this program. The information you have provided completing this form will be disclosed by your employer to the State Workforce Agency. Provision of this information is voluntary; however the information is required to determine your employer's eligibility for the federal tax credit. Public Burden Statement: Persons are not required to respond to this collection of information unless it displays a currently valid OM B control number. Respondents' obligation to complete this form is required to obtain or retain benefits (P.L ). Public reporting burden is estimated to average 10 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of Information. Send comments regarding this burden estimate to the U.S. Department of Labor, Division of National Programs Tools Technical Assistance, Room C-4510, Washington, D.C (Paperwork Reduction Project ). Please do not submit completed forms to this address. ETA Form 9175 (May 2016)