Annual Review of Driving Record

Transcription

1 Annual Review of Driving Record Motor Carrier Instructions: Each motor carrier shall at least once every 12 months, require each driver to prepare and furnish it with a list of all violations of motor vehicle traffic laws and ordinances (other than parking) of which the driver has been convicted, or on account of which he/she has forfeited bond or collateral during the preceding 12 months ( ). Drivers who have provided information required by need not repeat that information on this form. Driver Requirements: Each driver shall furnish the list as required by the motor carrier above. If the driver has not been convicted of, or forfeited bond or collateral on account of any violation which must be listed, he/she shall so certify ( ). Driver s Printed Name Social Security Number Completed by Driver Certification of Violations Hire DL Number State Exp 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. If you have had NO violations, please indicate by writing NONE Offense Location Type of Vehicle of Certification Driver s Signature Completed by Motor Carrier Annual Review of Driving Record I have hereby reviewed the driving record of the above named driver in accordance with and find that he/she (check one): Meets minimum requirements of safe driving. Does not adequately meet satisfactory safe driving performance. Is disqualified to drive a motor vehicle pursuant to Action Taken With Driver Reviewed By (Print) Signature Title MVR Annual Review 11/07/12

2 STARTING THE BACKGROUND SCREENING PROCESS Rexus Corporation s national headquarters is in Charlotte, North Carolina. To ensure best results, the client shares information with Rexus following the procedure below: We recommend that you contact Rexus before beginning to discuss which background investigations are best for your company. To start the process, fax or Job application Resume (if available) Signed Disclosure and Release form Work Request form to Rexus at or to billy.ensley@rexus.com. Online services for submission are also available. When Rexus completes the work, we will return a report to you as soon as possible by , fax, or regular mail, based on your preference. We encrypt all incoming and outgoing information and send documents in PDF format. You can also retrieve reports online via secure portal access. Rexus needs your contact person s telephone number, fax number, and address so that we know where to direct information. We recommend when possible. Are there any special instructions? For example, does Rexus need to call the contact person before sending reports, or can we send reports when complete? If you have applications which will be sent from multiple locations, please let us know so that Rexus can inform your key people with details of the process. For any questions concerning start-up procedures, please contact Billy Ensley, Chief Operating Officer, at or billy.ensley@rexus.com.

3 BACKGROUND SCREENING WORK REQUEST Client: Name: Savanna Well Servicing Site: Dickinson, ND Contact: Coley Hueske Phone Number: Fax Number: Address: Applicant Name: Position Applied For: Location/Code: Search items requested for this applicant: National Bankruptcy Search Business References Civil Records Education Verification Employment Verification Federal Criminal Records Circle: National or One district Motor Vehicle Records Municipal (County) Criminal Records Felonies and Misdemeanors Social Security Number Verification Personal Credit Report Personal References Professional Licenses and Certifications Verification Statewide Repository Criminal Records Felonies and Misdemeanors Sexual Predators Registry 10-Panel Drug Screening Office of Foreign Assets Control OFAC (National Terrorists Watch Lists Search) Free to all clients Please or fax this request to or call

4 DISCLOSURE AND RELEASE In connection with my application for employment with Savanna Energy Services, I understand that a background report may be requested at will by Savanna Energy Services. This report may include such information as: education, former employment, driving record, credit, bankruptcy proceedings, criminal records, etc., from federal, state, and other agencies which maintain such records. As set forth in the Fair Credit Reporting Act, I have the right to request from Savanna Energy Services, and the report provider, upon proper identification, the nature and substance of the information obtained from the background report. I authorize any party or agency contacted by Savanna Energy Services or its authorized representatives, to furnish the above-described information. I hereby authorize procurement of the background report. Applicant Signature Name (Please Print) Applicant: Please complete the following for proper identification purposes. Name: Last First Middle Maiden Social Security Number of Birth List all other last names or maiden names used CONTINUED ON NEXT PAGE

5 (CONTINUED) Applicant Name: List ALL addresses for past 10 years: Current Address: City County State Zip How Long? Previous Address: City County State Zip How Long? Previous Address: City County State Zip How Long? Previous Address: City County State Zip How Long? Previous Address: City County State Zip How Long? Previous Address: City County State Zip How Long? Driver's License Number and State List any other names or Social Security Numbers you have used. List any criminal convictions. Provide the date(s), county/parish, and state.

6 Part 1 Safety Performance History Records Request To Be Completed By Prospective Employee I, First M.I. Last Hereby authorize: Previous Employer Street Address Social Security Number DOB Phone City, State, Zip Fax To release and forward the information requested by Part 3 of this document concerning my Alcohol and Controlled Substances records within the previous 3 years from: Application To: Prospective Employer Savanna Well Servicing Attention Street Address 3056 HWY 22 Phone City, State, Zip Dickinson, ND Fax Address In compliance with 40.25(g) and (h), release of this information must be made in a written form that ensures confidentiality, such as a fax, or letter. Applicant Signature Part 2 To Be Completed By Previous Employer Accident History The applicant named above was employed by us Yes No Position From (mm/yy) To (mm/yy) Did he/she drive a motor vehicle Yes No If yes, type? Strait Truck Tractor Semitrailer Bus (Specify Cargo Tank Doubles/Triples Other Other) Reason for leaving your employ Discharged Resignation Lay Off Military Duty If there is no safety performance history to report, check none, sign below and return None Accidents: Complete the following for any accidents included on your accident register that involved the applicant in the 3 years prior to the application date shown above or check none None Location # Injuries # Fatalities Hazmat Spill Please provide information concerning any other accidents involving the applicant that were reported to government agencies or insurers or retained under internal company policies: Any other remarks: Signature Title Part 3 To Be Completed By Previous Employer Drug and Alcohol History If the driver was not subject to DOT testing requirements while employed by you, please fill in the dates of employment, complete the bottom of Part 3, sign and return. From (mm/yy) To (mm/yy) 1 Safety History Request 11/07/12

7 Safety Performance History Records Request Part 3 (cont) To Be Completed By Previous Employer Drug and Alcohol History Driver was subject to DOT testing requirements From (mm/yy) To (mm/yy) 1) Has this person had an alcohol test with the result of 0.04 or higher alcohol concentration? Yes No 2) Has this person tested positive, adulterated or substituted a test specimen for controlled substances? Yes No 3) Has this person refused to submit to a post-accident, random, reasonable suspicion, or follow up alcohol or controlled substance test? Yes No 4) Has the person committed other violations of Subpart B or Part 382, or Part 40? Yes No 5) If this person has violated a DOT drug and alcohol regulation, did this person complete a SAP-prescribed rehabilitation program in your employ, including return-to-duty and follow-up tests? If yes, please send documentation back with this form. Yes No 6) For a driver who successfully completed a SAP s rehabilitation referral and remained in your employ, did this driver subsequently have an alcohol test result of 0.04 or greater, a verified positive drug test, or refuse to be tested? Not Applicable Yes No In answering these questions, include any required DOT drug or alcohol testing information obtained from prior previous employers in the previous 3 years prior to the application date shown on page 1. Company Name Street Address Phone City, State, Zip Completed By (Print) Signature Part 4a To Be Completed By Prospective Employer This form was Faxed to Previous Employer Mailed ed Other (Specify) By Part 4b To Be Completed By Prospective Employer To be completed when information is obtained. Information received from Recorded by Method Faxed from Previous Employer Mailed ed Other (Specify) Instructions to complete the safety performance history records request Part 1: Prospective Employee Complete the Required Information Sign and Submit to the Prospective Employer Part 2: Prospective Employer Complete the Required Information Send to Previous Employer Part 3: Previous Employer Complete the Required Information Sign and Return to Prospective Employer Part 4: Prospective Employer Complete the Required Information Retain the Form 2 Safety History Request 11/07/12

8 DRIVER S APPLICATION FOR EMPLOYMENT Applicant Name (print) Company Address of Application City State Zip In compliance with Federal and State equal employment opportunity laws, qualified applicants are considered for all positions without regard to race, color, religion, sex, national origin, age, marital status, veteran status, non-job related disability, or any other protected group status. 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 result 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 employers may be used, and those employer(s) will be contacted, for the purpose of investigating my safety performance history as required by 49 CFR (d) and (e). I understand that I have the right to: Review information provided by 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. Signature FOR COMPANY USE PROCESS RECORD APPLICANT HIRED DATE EMPLOYED DEPARTMENT (IF REJECTED, SUMMARY REPORT OF REASONS SHOULD BE PLACED IN FILE) REJECTED POINT EMPLOYED CLASSIFICATION SIGNATURE OF INTERVIEWING OFFICER TERMINATION OF EMPLOYMENT DATE TERMINATED DEPARTMENT RELEASED FROM DISMISSED VOLUNTARILY QUIT OTHER TERMINATION REPORT PLACED IN FILE SUPERVISOR This form is made available with the understanding that J. J. Keller & Associates, Inc. is not engaged in rendering legal, accounting, or other professional services. J. J. Keller & Associates, Inc. assumes no responsibility for the use of this form, or any decision made by an employer which may violate local, state, or federal law. Copyright 2005 J. J. KELLER & ASSOCIATES, INC., Neenah, WI USA (800) Printed in the United States 15F (Rev. 2/05) 691

9 APPLICANT TO COMPLETE (answer all questions - please print) Position(s) Applied for Name Last First Middle Social Security No. List your addresses of residency for the past 3 years. Current Address Street City Previous Addresses Phone How Long? State Zip Code yr./mo. How Long? Street City State & Zip Code yr./mo. How Long? Street City State & Zip Code yr./mo. How Long? Street City State & Zip Code yr./mo. Do you have the legal right to work in the United States? of Birth / / Can you provide proof of age? (Required for Commercial Drivers) Have you worked for this company before? Where? s: From To Rate of Pay Position Reason for leaving Are you now employed? If not, how long since leaving last employment? Who referred you? Have you ever been bonded? (Answer only if a job requirement) Have you ever been convicted of a felony? Rate of pay expected Name of bonding company If yes, please explain fully on a separate sheet of paper. Conviction of a crime is not an automatic bar to employment-all circumstances will be considered. Is there any reason you might be unable to perform the functions of the job for which you have applied [as described in the attached job description]? If yes, explain if you wish. EMPLOYMENT HISTORY All driver applicants to drive in interstate commerce must provide the following information on all employers during the preceding 3 years. List complete mailing address, street number, city, state and zip code. Applicants to drive a commercial motor vehicle* in intrastate or interstate commerce shall also provide an additional 7 years information on those employers for whom the applicant operated such vehicle. (NOTE: List employers in reverse order starting with the most recent. Add another sheet as necessary.) EMPLOYER NAME ADDRESS CITY STATE ZIP CONTACT PERSON PHONE NUMBER DATE FROM TO MO. YR. MO. YR. POSITION HELD SALARY/WAGE REASON FOR LEAVING 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 AND ALCOHOL TESTING REQUIREMENTS OF 49 CFR PART 40? YES NO PAGE 2 15F (Rev. 2/05) 691

10 EMPLOYMENT HISTORY (continued) EMPLOYER NAME ADDRESS CITY STATE ZIP CONTACT PERSON PHONE NUMBER DATE FROM TO MO. YR. MO. YR. POSITION HELD SALARY/WAGE REASON FOR LEAVING 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 AND ALCOHOL TESTING REQUIREMENTS OF 49 CFR PART 40? YES NO EMPLOYER NAME ADDRESS CITY STATE ZIP CONTACT PERSON PHONE NUMBER DATE FROM TO MO. YR. MO. YR. POSITION HELD SALARY/WAGE REASON FOR LEAVING 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 AND ALCOHOL TESTING REQUIREMENTS OF 49 CFR PART 40? YES NO EMPLOYER NAME ADDRESS CITY STATE ZIP CONTACT PERSON PHONE NUMBER DATE FROM TO MO. YR. MO. YR. POSITION HELD SALARY/WAGE REASON FOR LEAVING 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 AND ALCOHOL TESTING REQUIREMENTS OF 49 CFR PART 40? YES NO EMPLOYER NAME ADDRESS CITY STATE ZIP CONTACT PERSON PHONE NUMBER DATE FROM TO MO. YR. MO. YR. POSITION HELD SALARY/WAGE REASON FOR LEAVING 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 AND ALCOHOL TESTING REQUIREMENTS OF 49 CFR PART 40? YES NO EMPLOYER NAME ADDRESS CITY STATE ZIP CONTACT PERSON PHONE NUMBER DATE FROM TO MO. YR. MO. YR. POSITION HELD SALARY/WAGE REASON FOR LEAVING 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 AND ALCOHOL TESTING REQUIREMENTS OF 49 CFR PART 40? YES NO *Includes vehicles having a GVWR of 26,001 lbs. or more, vehicles designed to transport 16 or more passengers (including the driver), or any size vehicle used to transport hazardous materials in a quantity requiring placarding. The Federal Motor Carrier Safety Regulations (FMCSRs) apply to anyone operating a motor vehicle on a highway in interstate commerce to transport passengers or property when the vehicle: (1) weighs or has a GVWR of 10,001 pounds or more, (2) is designed or used to transport more than 8 passengers (including the driver), OR (3) is of any size and is used to transport hazardous materials in a quantity requiring placarding. PAGE 3 15F (Rev. 2/05) 691

11 ACCIDENT RECORD FOR PAST 3 YEARS OR MORE (ATTACH SHEET IF MORE SPACE IS NEEDED) IF NONE, WRITE NONE NATURE OF ACCIDENT DATES FATALITIES INJURIES (HEAD-ON, REAR-END, UPSET, ETC.) HAZARDOUS MATERIAL SPILL LAST ACCIDENT NEXT PREVIOUS NEXT PREVIOUS TRAFFIC CONVICTIONS AND FORFEITURES FOR THE PAST 3 YEARS (OTHER THAN PARKING VIOLATIONS) IF NONE, WRITE NONE LOCATION DATE CHARGE PENALTY (ATTACH SHEET IF MORE SPACE IS NEEDED) EXPERIENCE AND QUALIFICATIONS DRIVER List all driver licenses or permits held in the past 3 years DRIVER LICENSES STATE LICENSE NO. TYPE EXPIRATION DATE A. Have you ever been denied a license, permit or privilege to operate a motor vehicle? YES NO B. Has any license, permit or privilege ever been suspended or revoked? YES NO IF THE ANSWER TO EITHER A OR B IS YES, GIVE DETAILS DRIVING EXPERIENCE CHECK YES OR NO CLASS OF EQUIPMENT CIRCLE TYPE OF EQUIPMENT DATES APPROX. NO. OF MILES FROM (M/Y) TO (M/Y) (TOTAL) STRAIGHT TRUCK YES NO (VAN, TANK, FLAT, DUMP, REFER) TRACTOR AND SEMI-TRAILER YES NO (VAN, TANK, FLAT, DUMP, REFER) TRACTOR - TWO TRAILERS YES NO (VAN, TANK, FLAT, DUMP, REFER) TRACTOR - THREE TRAILERS YES NO (VAN, TANK, FLAT, DUMP, REFER) MOTORCOACH - SCHOOL BUS More than 8 YES NO passengers MOTORCOACH - SCHOOL BUS More than 15 YES NO passengers OTHER LIST STATES OPERATED IN FOR LAST FIVE YEARS: SHOW SPECIAL COURSES OR TRAINING THAT WILL HELP YOU AS A DRIVER: WHICH SAFE DRIVING AWARDS DO YOU HOLD AND FROM WHOM? EXPERIENCE AND QUALIFICATIONS OTHER SHOW ANY TRUCKING, TRANSPORTATION OR OTHER EXPERIENCE THAT MAY HELP IN YOUR WORK FOR THIS COMPANY LIST COURSES AND TRAINING OTHER THAN SHOWN ELSEWHERE IN THIS APPLICATION LIST SPECIAL EQUIPMENT OR TECHNICAL MATERIALS YOU CAN WORK WITH (OTHER THAN THOSE ALREADY SHOWN) EDUCATION CIRCLE HIGHEST GRADE COMPLETED: HIGH SCHOOL: COLLEGE: LAST SCHOOL ATTENDED (NAME) (CITY, STATE) TO BE READ AND SIGNED BY APPLICANT This certifies that this application was completed by me, and that all entries on it and information in it are true and complete to the best of my knowledge. Signature: PAGE 4 15F (Rev. 2/05) 691 :

12 Pre-Employment Drug Testing Policy Federal law requires applicants to indicate whether they have previously refused to be tested or received a positive test result on any pre-employment for any other DOT employer. Please provide this information below. It is a federal offense to falsify this information. I have NOT tested positive on a pre-employment drug test for any other DOT employer in the past TWO years, nor have I refused to be tested. Yes, I have tested positive (or refused to be tested) on a pre-employment drug test for another DOT employer in the past TWO years. (If yes, please sign below, and do not continue.) Print Name Driver s Signature Each applicant for a DOT-covered position at Savanna Well Servicing, after being notified that he/she will be offered a job, must be drug tested, in accordance with federal regulations 49 CFR Part 382. If the test result is positive, or if the applicant refuses to submit to a pre-employment test, the job offer will be withdrawn. We must have a negative test result in our file before we can request or allow an employee to perform duties within any of our safety-sensitive positions. A positive dilute drug test will be considered to be a positive test. A negative dilute drug test (or invalid specimen) will result in the employee being required to immediately take another test, with minimum notice. Every applicant who provides a positive test result will have an opportunity to speak with a Medical Review Officer about any recent use of prescription and non-prescription drugs that might explain the positive test result. The cost of the initial screening test and the confirmatory test will be paid by Savanna Well Servicing. Every applicant whose test result is positive may, within 72 hours, request a re-test at his/her own expense. The re-test will be conducted on the same sample as was provided for the initial test and must be conducted by a different certified testing laboratory. My signature below means that I have read this information, that I have had an opportunity to review a copy of the Savanna Well Servicing drug and alcohol policy, and that if I am offered a position, I consent to being tested for drugs as a condition of employment. Print Name Driver s Signature (Original to be kept in Driver Qualification File) THIS POLICY IS NOT AN EMPLOYMENT CONTRACT OR AN OFFER OF AN EMPLOYMENT CONTRACT.