|
|
- Milo Roger West
- 5 years ago
- Views:
Transcription
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15 GAVIOTA GAS PLANT CO. MOTOR CARRIER SAFETY SURVEY Carrier Name a. Organized driver training provided for Address Home/Office Company Drivers: N E Owner-Operators: N E Interview Location b. Length of training sessions: New drivers Carrier Personnel Interviewed c. Frequency of ongoing training: Make-Up sessions provided: N E Date of Interview d. Type of training used: Type of Carrier: Truck Lead LTL Bulk Tank Lecture: N E Services Performed: Contract Common Carrier Tape/slide: N E Equipment: Tractors owned by company Total: Video Cassette: N E Tractors owned by owner/operator Total: Literature: Self-taught: N E Replacement Policy: Other (specify): N Trailers/Tanks owned by company Total: Other (specify): E Trailers/Tanks owned by owner/operator Total: e. Topics covered Replacement Policy: Tanks / Trailers: Speeding Policy: N E Drivers: Company Drivers (No.) Alcohol/narcotics/drug abuse: N E Owner/Operators (No.) Hazardous material identification on Shipping papers: N E Company Safety Indicators Placarding: N E a. DOT reportable accident rate per million vehicle miles: Emergency procedures N E Current year Previous year Two years previous Emergency communications: Internal N E b. Insurance premium cost per one hundred dollars of gross receipts: Emergency Communications: CHEMTREC N E Current year Previous year Two years previous Rail/highway grade crossing procedures N E c. Insurance Carrier(s) Vehicle inspections: N E Liability limits Deductible Drivers Logs: N E d. Is cargo insurance carried? Loading/bracing/blocking: N E e. Does your insurance extend to subhaulers? Customer site safety rule policy: N E f. Current Bureau of Motor Carrier Safety (BMCS) rating Specific to bulk trucks: g. Date of last BMCS safety survey Loading/unloading procedure: N E h. Citations/fines, if any, by DOT during past three years Equipment operation: N E Equipment inspection: N E Customer requirements: N E Driver Qualifications Immediate emergency response measures: N E Company Drivers Other topics (list): N a. Minimum age b. Road experience Other topics (list): E c. Company road test f. Training administered by: d. New physical exam approved by doctor Company staff: N E e. Number of moving violations permitted Driver/trainer: N E f. Number of reportable accidents permitted Professional firm: N E g. Disqualifications (list) g.records of training subjects maintained for h. Previous employment history check: How many years each driver? N E i. MVR review: Yes No Period examined j. Screening tests employed (list) Driver Management a. Do you have a speed limit policy? Yes _ No _ k. Decision to hire made by (list title) If yes, list policy b. Do you have speed controls on equipment? Yes _ No _ l. Educational requirements If yes, list controls m. Other (list) c. Do you use Company surveillance of driver performance including speeding? d. Do you use outside agents to monitor drivers Owner/Operators speeding or other driving problems? Yes _ No _ a. List requirements If yes, list agent e. Are drivers required to report traffic Driver Training (Place X after N if item applies to new drivers and X after E if item applies to existing drivers.) violations? Yes _ No _ If yes, when/where f. Do you have policies for logging violations?yes _ No _ How handled Written Verbal Other
16 g. Are complaints recorded? Yes No e. Safety/emergency h. Tires Reviewed with driver? Yes No equipment i. Couplings & h. Does carrier recognize safety performance? Yes No f. Lights air hose condition (Attach details if yes) g. Windshield glass j. Fifth wheel lube i. Are passengers allowed in cab? Yes No & locking j. Who handles/maintains hazardous materials permits? Local terminal Other Items checked - trailers k. Does carrier conduct driver performance reviews? Yes No a. Undercarriage e. Brake adjustment If yes, Frequency b. Tires f. Lights l. Does carrier have on-going safety program? Yes No c. Floor g. Door Tie-back If yes, list programs d. Sidewalls h. Door Latches Equipment Maintenance Incident Communications a. Where performed: Company shop Outside shop a. CFR 49 Section Reporting Accidents b. Scheduled (PM) maintenance frequency How is the above reviewed with driver? Trailers: Classroom Tractors: A. B. C. Driver Training c. Major overhaul interval Driver Reads Regulations only d. Tire replacement policy Other List Steering axle b. Are trip packs provided for drivers to Tractor drive axle use for accident handling? Yes No Trailer c. Is a written accident report required of driver? Yes No Recaps used: Yes No If yes, where If no, who prepares? List e. How is maintenance service audited? d. Who calls local authorities when accidents occur? Driver Dispatcher Cargo tank Inspection and Testing Safety Supervision a. Where are visual inspections performed? Other List Company facility Outside facility e. Who calls CHEMTREC if required? ( ) b. Where is hydrostatic testing performed? Driver Company facility Outside facility Dispatch c. Where are relief valves bench tested and inspected: Safety Supervision Company facility Outside facility Other List d. Visual inspection interval: f. Is shipper notified of incidents? Yes No Cargo tanks other than MC 330, 331: g. Name and phone number of Chevron person that would be notified: e. Hydrostatic test interval MC 330, 331 tanks f. Pre-trip inspection procedures Emergency Response g. Post-trip inspection procedures a. Does carrier have emergency response capabilities? Yes No h. Program for checking relief valve/vent capacity b. If yes, list capabilities. adequacy c. Does carrier use outside services for emergency response? Yes No Safety Organization d. Does carrier have recovery drums? Yes No a. Organization structure (attach organization chart if e. How is response team activated? Driver calls Dispatch Calls available) Other b. To whom does person responsible foe safety report? Vehicle Inspections c. Is safety director/supervisor full time or part time job? Driver Pre-Trip: Yes No Form Used: Yes No Post-Trip: Yes No Form Used: Yes No Training Organization Inspection Follow-up: Mechanic Yes No a. Organization structure (attach organization chart if Shop Foreman: Yes No available) Other (specify): b. To whom does person responsible for training report? _ Shop Inspections: When/Frequency c. Is training director/supervisor full time or part time Items checked tractors: job? a. Steering mechanism c. Engine hose condition b. Brakes d. Fluid levels Hazardous Materials Experience HM classifications/years carried/percent of Business Notes/Comments:
17
18
19
TRANSPORTATION / HEAVY HAUL SUPPLEMENTAL APPLICATION
EFFECTIVE DATE: NAMED INSURED: MAILING ADDRESS: PHYSICAL ADDRESS: WEBSITE: PHONE: AGENCY NAME: PRIMARY CONTACT PERSON: FED TAX ID #: REPRESENTATIVE: AGENCY ADDRESS: GENERAL DESCRIPTION OF OPERATIONS: YEARS
More informationWeather Shield Transportation Ltd
Transportation Ltd. Driver s Application for Employment Weather Shield Transportation Ltd 642 Whelen Avenue, Medford, Wisconsin 54451 In compliance with Federal and State equal employment opportunity laws,
More informationLARGE FLEET TRUCKING APPLICATION CHECKLIST
RLI Transportation 2970 Clairmont Rd., Suite 1000 Atlanta, GA 30329 A division of RLI Insurance Company P: 404-315-9515 F: 404-315-6558 www.rlitransportation.com LARGE FLEET TRUCKING APPLICATION CHECKLIST
More informationApplication for Employment
Application for Employment Date of Application Signature: _ Signature: Date: U.S. Department of Transportation requires driver applicants to state their date of birth (391.21(b)(2)). month/day/year Applicant
More informationDRIVER S EMPLOYMENT APPLICATION
DRIVER S EMPLOYMENT APPLICATION Rapid Service Inc. 308 Pennsylvania Ave. Greer, SC 29650 MAP TEST LOGS HOME LOG TEST ROAD TEST In compliance with Federal and State equal employment opportunities laws,
More informationSalt Lake City Area Office 8722 S. Harrison St. Sandy, UT P.O. Box 4439 Sandy, UT Fax COMMERCIAL AUTO
Salt Lake City Area Office 8722 S. Harrison St. Sandy, UT 84070 P.O. Box 4439 Sandy, UT 84091 800-257-5590 Fax 800-478-9880 COMMERCIAL AUTO Chicago Office 303 W. Madison Street Suite 2075 Chicago, IL 60606
More informationLARGE FLEET TRUCKING APPLICATION CHECKLIST (50 or more Power Units)
RLI Transportation 2970 Clairmont Rd., Suite 1000 Atlanta, GA 30329 A division of RLI Insurance Company P: 404-315-9515 F: 404-315-6558 www.rlitransportation.com LARGE FLEET TRUCKING APPLICATION CHECKLIST
More informationPlease fill out the attached application and return it to our office. Please include the following:
Dear Prospective Independent Contractor: We strive to inform our applicants of every detail possible before offering a contract. We find that the better informed each applicant is, the better fit our drivers
More information5Star Submission Checklist & Questionnaire Trucking Program
5Star Submission Checklist & Questionnaire Trucking Program Agency Helpline ~ 877-247-9772 No coverage is effective until approved by the General Agent Send submissions to: FLORIDA 158 N. Harbor City Blvd,
More informationTideport Distributing, Inc De Zavala Rd Channelview, TX Phone: Fax:
Tideport Distributing, Inc. 16031 De Zavala Rd Channelview, TX 77530 Phone: 281-862-9668 Fax: 281-452-2865 ALL APPLICANTS _ In accordance with Federal regulations, please fill-in this application so that
More informationDESCRIPTION OF OPERATIONS. LIABILITY COVERAGE C Complete for desired coverages by indicating limits of insurance.
Special Types Application COLUMBIA INSURANCE COMPANY NATIONAL INDEMNITY COMPANY NATIONAL FIRE & MARINE INSURANCE COMPANY NATIONAL LIABILITY & FIRE INSURANCE COMPANY NATIONAL INDEMNITY COMPANY OF THE SOUTH
More informationA B C Hazardous Doubles/Triples Passenger Air Brake State License NO. Class (check one) Endorsements (Check those you have now) Expiration Date
3 DRIVING EXPERIENCE AND QUALIFICATION Licenses Drivers Licenses held in the past three years must be shown. (Attach separate sheet if more space is needed.) If none, check here A B C Hazardous Doubles/Triples
More informationApplication for Employment Driver
3720 River Rd. Suite 100 Franklin Park, IL 60131 (847) 616-1080 phone (630)766-6339 fax www.rmtrucking.com email: hr@rmtrucking.com 5120 S. International Drive Cudahy, WI 53110 (414) 294-5800 phone (414)
More informationBasin Concrete & Trucking. Dear Basin Concrete Applicant,
Dear Basin Concrete Applicant, As part of our hiring process we have provided you with this application packet for you to complete. In order to make your hiring process flow as easily as possible the guidelines
More informationAutomobile Liability Insurance Commercial Vehicles (U.S.A.) Proposal Form
Automobile Liability Insurance Commercial Vehicles (U.S.A.) Proposal Form INSURED: DBA: Physical Address: Mailing Address: ICC Docket MC: Type of Carrier: DESIRED COVERAGE Auto Liability DOT: Common Private
More informationPosition(s) Applied for. Name Social Security No Last First Middle. How Long. How Long. How Long
APPLICATION FOR EMPLOYMENT 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
More informationAPPLICATION FOR EMPLOYMENT
APPLICANT STATEMENT I certify by my signature below that all of the information I have provided in order to apply for and secure work with the employer is true, complete and correct. I understand that
More information. Union Environmental, LLC Driver Minimum Qualifications
. Union Environmental, LLC Driver Minimum Qualifications Please check each qualification you meet. All applicants must meet or exceed the following standards: Minimum age 24 2 years verifiable tractor/trailer
More informationTEXAS VOLUNTEER FIRE DEPARTMENT MOTOR VEHICLE SELF INSURANCE PROGRAM APPLICATION FOR VEHICLE LIABILITY INSURANCE
TEXAS VOLUNTEER FIRE DEPARTMENT MOTOR VEHICLE SELF INSURANCE PROGRAM APPLICATION FOR VEHICLE LIABILITY INSURANCE FOR TEXAS A&M FOREST SERVICE USE ONLY VFD CASE# COUNTY NOTE: ALL QUESTIONS MUST BE ANSWERED
More informationDRIVER'S APPLICATION PACKET
Physical Address Contact Information 1418 E Elgin St Phone: (208) 459-0271 Caldwell, ID 83605 Fax: (208) 459-0287 Human Resources/Recruitment Director Nick Shanley Nick@RST208.com DRIVER'S APPLICATION
More informationTRUCKERS APPLICATION
DEEP SOUTH TRUCKERS APPLICATION PROPOSAL FORM - PRIMARY COVERAGE/COMMERCIAL TRUCKMEN REQUIRED FOR 10 OR MORE POWER UNITS THAT ARE ICC REGULATED **IMPORTANT - PLEASE NOTE** ALL ITEMS MUST BE COMPLETED IN
More informationDESCRIPTION OF OPERATIONS. LIABILITY COVERAGE Complete for desired coverages by indicating limits of insurance.
Special Types Application COLUMBIA INSURANCE COMPANY NATIONAL FIRE & MARINE INSURANCE COMPANY NATIONAL INDEMNITY COMPANY NATIONAL INDEMNITY COMPANY OF MID-AMERICA NATIONAL INDEMNITY COMPANY OF THE SOUTH
More informationDESCRIPTION OF OPERATIONS. LIABILITY COVERAGE Complete for desired coverages by indicating limits of insurance.
Special Types Application COLUMBIA INSURANCE COMPANY NATIONAL FIRE & MARINE INSURANCE COMPANY NATIONAL INDEMNITY COMPANY NATIONAL INDEMNITY COMPANY OF MID-AMERICA NATIONAL INDEMNITY COMPANY OF THE SOUTH
More informationMono-Line Transportation Pollution Liability Application
Mono-Line Transportation Pollution Liability Application IMPORTANT NOTICE: All questions in this application must be answered. If your answer is "none", "not applicable", or "do not know", please state
More informationEMPLOYMENT APPLICATION
of Application: EMPLOYMENT APPLICATION Email Address: What position are you applying for? Motorcoach Operator Vehicle Service Technician Mechanic Inside Sales/Customer Service Dispatcher Other: Full Name:
More informationEmployment Application
Employment Application You MUST answer every question. If any question does not apply to you, answer with Not Applicable (NA). Name: Last First Middle Initial Social Security No. Address: Length of residency:
More informationColgate University Driver Safety and Motor Vehicle Use Policy
Purpose Colgate University Driver Safety and Motor Vehicle Use Policy This policy provides employee and student requirements for operation of Colgate University owned, leased, or rented motor vehicles,
More informationD E E P S O U T H O F T E N N E S S E E
5 410 MARYLAND WAY, SUITE 41 0, B RENTWOOD, TN 3 7027 P H O N E : 6 1 5. 8 3 2. 8 9 0 0 o r 8 8 8. 8 3 2. 8 9 0 0 F A X : 6 1 5. 8 3 2. 5 4 3 4 o r 8 8 8. 8 3 2. 8 9 0 1 TRUCKERS APPLICATION PROPOSAL FORM
More informationCOMMERCIAL AUTOMOBILE/TRUCKERS APPLICATION
Mid Valley General Agency LLC 888 Madison St NE, Ste 100, Salem, OR 97301 Phone: 888-565-7001 Fax: 888-265-7353 quotes@midvalleyga.com COMMERCIAL AUTOMOBILE/TRUCKERS APPLICATION Name of Applicant: Agent
More informationHAZARDOUS MATERIAL SUPPLEMENTAL APPLICATION (Complete in addition to the Commercial Automobile Application)
National Casualty Company Home Office: Madison, Wisconsin Scottsdale Insurance Company Home Office: One Nationwide Plaza Columbus, Ohio 43215 1-800-423-7675 Fax (480) 483-6752 www.scottsdaleins.com Scottsdale
More informationAPPLICATION FOR EMPLOYMENT
6003 STATE ROAD 76, OSHKOSH, WI 54904 APPLICATION FOR EMPLOYMENT In compliance with Federal and State equal employment opportunity laws, qualified applicants are considered for all positions without regard
More informationDriver Management Policy
Driver Management Policy Introduction Proper selection and training of new employees is a key element in any safety program, but it is especially important when selecting new drivers. The following procedures
More informationAPPLICATION FOR QUALIFICATION
APPLICATION FOR QUALIFICATION Company Wynne Transport Service, Inc. 2222 N 11 th Street City Omaha State NE Zip 68110 The purpose of this application is to determine whether or not that applicant is qualified
More informationCONTRACTOR APPLICATION
DD&S Express, Inc. 185 Harry S Truman PKWY, Suite 116 Annapolis MD 21401 410-488-9200 Ext 1492 Fax: 301-386-0709 applications@ddsexpress.com 1 of 5 CONTRACTOR APPLICATION In compliance with Federal and
More informationDRIVER QUALIFICATION APPLICATION
DRIVER QUALIFICATION APPLICATION 6800 Port Road, Groveport, OH 43125 This application must be completed in ink in applicant s own handwriting. Note: Please answer or check all questions. If the answer
More informationSANILAC COUNTY ROAD COMMISSION EMPLOYMENT APPLICATION FOR CDL POSITION 35 N. Flynn Street Sandusky, MI 48471
SANILAC COUNTY ROAD COMMISSION EMPLOYMENT APPLICATION FOR CDL POSITION 35 N. Flynn Street Sandusky, MI 48471 (810) 648-2185 FAX (810) 648-5810 Equal access to programs, services, and employment is available
More informationName Social Security No. Last First Middle Address. State, Zip Phone Zip ADDRESS. How Long. Do you have the legal right to work in the United States
Arkansas Equipment Leasing Application P.O. Box 905 Mabelvale, AR 72103 In compliance with Federal and State equal employment opportunity laws, qualified applicants are considered for all positions without
More informationFIRE & MARINE INSURANCE COMPANY
Truck Application COLUMBIA INSURANCE COMPANY NATIONAL FIRE & MARINE INSURANCE COMPANY NATIONAL INDEMNITY COMPANY NATIONAL INDEMNITY COMPANY OF MID-AMERICA NATIONAL INDEMNITY COMPANY OF THE SOUTH NATIONAL
More informationCOLUMBIA INSURANCE COMPANY
Truck Application COLUMBIA INSURANCE COMPANY NATIONAL FIRE & MARINE INSURANCE COMPANY NATIONAL INDEMNITY COMPANY NATIONAL INDEMNITY COMPANY OF MID-AMERICA NATIONAL INDEMNITY COMPANY OF THE SOUTH NATIONAL
More informationAPPLICATION FOR DRIVERS
4601 TX-349 Midland,Texas 79706 (432) 617-4999 APPLICATION FOR DRIVERS You must answer every question. If any question does not apply to you, answer with Not Applicable (NA). In compliance with local,
More informationCommercial Auto Questionnaire
Commercial Auto Questionnaire This questionnaire is to be completed in conjunction with Acord 137. Complete Acord 45 if Additional Insureds, Loss Payees or certificates of insurance are need. Complete
More informationTruck Application DESCRIPTION OF OPERATIONS
Truck Application Policy Term From: 1. Name (and "dba") Individual/Proprietorship Partnership Corporation Other Business Phone Number 2. Mailing Address City State Zip 3. Premises Address City State Zip
More informationDRIVER QUALIFICATION APPLICATION
VSS TRANSPORTATION GROUP 1325 W BELTLINE RD. CARROLLTON, TX 75006 TEL: 469-568-6380/ 1-800-697-0561 FAX: 888-363-9923 E-MAIL HR@VSSCARRIERS.COM DRIVER QUALIFICATION APPLICATION If you feel your civil rights
More informationCanal Truck Insurance Application
Canal Truck Insurance Application Insurance Indemnity Sections 1 through 6 must be completed for a quote indication. Sections 7 through 9 must be completed in order to bind. 1. General Information Applicant
More informationDRIVER QUALIFICATION APPLICATION
Agent/Terminal # Recruiter DRIVER QUALIFICATION APPLICATION Thank you for your interest in one of our Greatwide Truckload Management Carriers. Please read and complete this application. Be sure to sign
More informationDRIVER S APPLICATION FOR EMPLOYMENT
DRIVER S APPLICATION FOR EMPLOYMENT (Answer all questions please print) In compliance with Federal and Provincial equal employment opportunities laws, qualified applicants are considered for all positions
More informationCF LOGISTICS LLC. PO Box 686, Avondale, PA Phone: Fax:
CF LOGISTICS LLC Form DQ-Cover1 Thank you for your interest in becoming a Professional CDL Driver with CF Logistics LLC We understand that the information you provide us on this application is very sensitive
More informationTruck Driver Application for Employment
Truck Driver Application for Employment NAME Last First Middle LIST YOUR ES OF RESIDENCY FOR THE PREVIOUS THREE (3) YEARS. CURRENT Street City ( ) State Zip Code Telephone How Long? (yr./mo.) PREVIOUS
More informationGARAGE LIABILITY APPLICATION
Date: GARAGE LIABILITY APPLICATION Agency: Phone: Producer: Fax: Please include the following with all applications: Current MVR s for all drivers Complete Vehicle & Equipment Schedule 1. General Information
More informationAUTOMOBILE PHYSICAL DAMAGE INSURANCE COMMERCIAL VEHICLES (U.S.A.) APPLICATION
AUTOMOBILE PHYSICAL DAMAGE INSURANCE COMMERCIAL VEHICLES (U.S.A.) APPLICATION 1. Name of Applicant: 2. Address City State Zip 3. Address of Principal Terminal if other than above: 4. Radius of Operation:
More informationNANCY BAER TRUCKING, INC. FAX #: (812) DATE OF APPLICATION: COMPANY: NANCY BAER TRUCKING, INC. ADDRESS:
NANCY BAER TRUCKING, INC. FAX #: (812) 482-2118 DATE OF APPLICATION: COMPANY: NANCY BAER TRUCKING, INC. ADDRESS: 3137 VIRGINIA AVENUE JASPER, INDIANA 47546 In compliance with Federal and State equal opportunity
More informationLast Name First Name Middle Initial. City State Zip
PLEASE PRINT APPLICATION FOR EMPLOYMENT We consider applications for all positions without regard to race, color, religion, gender, sexual orientation, age, marital or veteran status, disability, or any
More informationAPPLICATION FOR QUALIFICATION
Company FMC Transport Fax # 417-469-2599 Address P.O. Box 218 City Willow Springs State MO ZIP Code 65793 The purpose of this application is to determine whether or not the applicant is qualified to operate
More informationNOW Courier, Inc. COMMERCIAL DRIVER APPLICATION FILL IN ALL BLANKS & PROVIDE ALL INFORMATION REQUESTED--PRINT OR TYPE
July 2003, dlnm NOW Courier, Inc. P.O. Box 6066 Indianapolis, IN, 46206 COMMERCIAL DRIVER APPLICATION FILL IN ALL BLANKS & PROVIDE ALL INFORMATION REQUESTED--PRINT OR TYPE. Date: (317) 638-7071 Name: First
More informationARKANSAS SENATE 90th General Assembly - Regular Session, 2015 Amendment Form
ARKANSAS SENATE 90th General Assembly - Regular Session, 2015 Amendment Form Subtitle of Senate Bill No. 800 TO ENSURE THE SAFETY, RELIABILITY, COST-EFFECTIVENESS OF TRANSPORTATION NETWORK COMPANY SERVICES;
More informationROCK STAFFING DRIVER APPLICATION FOR EMPLOYMENT. Name: (First) (Middle) (Last) Address:
ROCK STAFFING DRIVER APPLICATION FOR EMPLOYMENT Date of application: / / Name: (First) (Middle) (Last) Address: (Street) (City) (State & Zip) How long at this address: Phone: Cell: Date of Birth: / / Social
More informationCourier Program Checklist
Complete, Save & email to csr@k2brokers.com OR Fax to 951 398 5170 Courier Program Checklist Owned Auto Completed Courier Questionnaire Completed Acord Applications Drivers List including: Name, DOB, Lic.
More informationArgenia, LLC Fairview Road Little Rock, AR (501) FAX: (501) DESCRIPTION OF OPERATIONS
Special Types Application COLUMBIA INSURANCE COMPANY NATIONAL INDEMNITY COMPANY NATIONAL FIRE & MARINE INSURANCE COMPANY NATIONAL LIABILITY & FIRE INSURANCE COMPANY NATIONAL INDEMNITY COMPANY OF THE SOUTH
More informationAnnual Review of Driving Record
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
More informationTransportation - Towing
Transportation - Towing Building a perfect submission is important when submitting new business to rman-spencer. Incomplete or inaccurate submissions often add time to the submission process, as well as
More informationOWNER-OPERATOR LEASE AGREEMENT
OWNER-OPERATOR LEASE AGREEMENT THIS AGREEMENT made and entered into this day of, 20 by and between hereinafter referred to as OWNER, and COYNE, INCORPORATED, 32830 IH 10 W, Boerne, Texas 78006, hereinafter
More informationWestWind Logistics, LLC
WestWind Logistics, LLC 1658 E Euclid Ave, Des Moines, IA 50313 (866) 455-1082 READ AND SIGN BEFORE SUBMITTING APPLICATION FOR QUALIFICATION I understand that the information in the Application for Qualification
More informationCANAL COMMERCIAL COMBINATION INSURANCE APPLICATION
CANAL INSURANCE COMPANY CANAL INDEMNITY COMPANY 1. Applicant legal name Applicant trade name (DBA) (if any) CANAL COMMERCIAL COMBINATION INSURANCE APPLICATION Proposed effective date & time: Proposed expiration
More informationBFI INDEPENDENT CONTRACTOR AGREEMENT Company: BFI Truck Lines LLC DBA BFI Hotshots
BFI INDEPENDENT CONTRACTOR AGREEMENT Company: BFI Truck Lines LLC DBA BFI Hotshots This agreement is made between the contractor as stated below and the Company as stated above. The company is to be referred
More informationPolicy Term From: To. Medical Payments
Truck Application COLUMBIA INSURANCE COMPANY NATIONAL FIRE & MARINE INSURANCE COMPANY NATIONAL INDEMNITY COMPANY NATIONAL INDEMNITY COMPANY OF MID-AMERICA NATIONAL INDEMNITY COMPANY OF THE SOUTH NATIONAL
More informationAPPLICATION FOR EMPLOYMENT *Applicant must complete in his or her own handwriting
APPLICATION FOR EMPLOYMENT *Applicant must complete in his or her own handwriting Date of Application / / Social Security Number / / Applicant Name Address City _ State Zip Home Phone Cell Phone Email
More informationSTONY RUN ENTERPRISES
STONY RUN ENTERPRISES Please follow these instructions for filling out the application. 1. Please save a blank copy of the form to your computer before filling it out. 2. Fill out the full application,
More information4. Chauffeur s licenses shall be required for MCCMH employees who transport members of the public in County-owned vehicles.
MCCMH MCO Policy 10-051 USE AND MAINTENANCE OF COUNTY / PERSONAL VEHICLES Date: 10/28/08 2. Each MCCMH employee shall be expected to read and adhere to the Macomb County Policy on the Use and Operation
More informationADDENDUM C VEHICLE OPERATIONS POLICY
ADDENDUM C VEHICLE OPERATIONS POLICY 1 VEHICLE OPERATIONS POLICY (from the Shasta County Personnel Rules, Chapter 33) SECTION 33.1. PURPOSE. Vehicle accidents pose a significant threat to public and personal
More informationAPPLICATION FOR EMPLOYMENT VEHICLE OPERATOR
NOTICE TO ALL APPLICANTS: Marvin Windows and Doors has a drug testing policy that requires drug testing as part of the post-conditional offer process for all applicants extended a conditional offer of
More informationDrive-A-Way/Toter Supplemental Application
National Casualty Company 8877 North Gainey Center Drive Scottsdale, Arizona 85258 Buschbach Insurance Agency, Inc. 5615 W. 95 th Street P. O. Box 5000 Oak Lawn, IL 60455-5000 708-423-2350 Fax: 708-425-5077
More informationAUBURN UNIVERSITY FLEET SAFETY POLICY
AUBURN UNIVERSITY FLEET SAFETY POLICY Managing the Risk Risk Management & Safety Effective Date: July 1, 2010 1 TABLE OF CONTENTS 1.0 Dedication to Vehicle Safety... 4 2.0 Requirements for Operations of
More informationAPPLICATION FOR EMPLOYMENT APPLICANT PROCEDURES TO BE READ AND SIGNED BY APPLICANT
Office Use Only DAC MVR REF R/T PHY D/S/R APPLICATION FOR EMPLOYMENT 7380 IH 10 EAST SAN ANTONIO, TX 78219 OFFICE PHONE: 210-662-0019 FAX: 210-572-7908 Application will remain active for 30 days. Any inquiries
More informationDOT APPLICATION FOR EMPLOYMENT
RES America Construction, Inc. 9050 N Capital of TX Hwy, Ste 390, Austin, TX 78759 DOT APPLICATION FOR EMPLOYMENT In compliance with Federal and State equal employment opportunity laws, qualified applicants
More informationDRIVER S APPLICATION FOR EMPLOYMENT
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
More informationApplication for Rental Autos & Trucks Short Term
Application for Rental Autos & Trucks Short Term (Hour, Day or Week) COLUMBIA INSURANCE COMPANY NATIONAL FIRE & MARINE INSURANCE COMPANY NATIONAL INDEMNITY COMPANY NATIONAL INDEMNITY COMPANY OF MID-AMERICA
More informationA Bill Regular Session, 2015 SENATE BILL 800
Stricken language would be deleted from and underlined language would be added to present law. 0 State of Arkansas 0th General Assembly As Engrossed: S// A Bill Regular Session, SENATE BILL 00 By: Senator
More informationTO BE READ AND SIGNED BY APPLICANT
TRUCK ONE, INC. INDEPENDENT CONTRACTOR SAFETY CLEARANCE FORM Note: Read and complete all portions of this proposal in your own handwriting (legible) in ink (Please print). Applications that are incomplete,
More informationLansberry Trucking, Inc.
WORK DESCRIPTION AND REQUIREMENTS TO BE AN OWNER- OPERATOR/INDEPENDENT CONTRACTOR (TRIAXLE AND OVER-THE-ROAD TRACTOR TRAILER) FOR LANSBERRY TRUCKING, INC. Be able to read and speak the English language
More informationCIRCULAR STATE OF NEW JERSEY DEPARTMENT OF THE TREASURY
CIRCULAR STATE OF NEW JERSEY DEPARTMENT OF THE TREASURY ORIGINATING NO.: 17-05-ADM AGENCY: DIVISION OF ADMINISTRATION PAGE 1 OF 7 EFFECTIVE EXPIRATION SUPERSEDES: 12-11-ADM DATE: 10-03-16 DATE: INDEFINITE
More informationApplication for Rental Autos & Trucks Short Term
Application for Rental Autos & Trucks Short Term (Hour, Day or Week) COLUMBIA INSURANCE COMPANY NATIONAL INDEMNITY COMPANY NATIONAL FIRE & MARINE INSURANCE COMPANY NATIONAL LIABILITY & FIRE INSURANCE COMPANY
More informationMAINE COMMUNITY COLLEGE SYSTEM
MAINE COMMUNITY COLLEGE SYSTEM HEALTH AND SAFETY Section 800.1 SUBJECT: PURPOSE: MOTOR VEHICLE PROCEDURE To promote the safe the authorized operation of motor vehicles operated on behalf, or for the benefit,
More informationWithholding and Reporting Requirements
Withholding and Reporting Requirements Relationships between workers and payers can vary. Your status may have tax and benefit implications. EMPLOYEES If you are an employee, your employer will deduct
More informationAN EQUAL OPPORTUNITY EMPLOYER/AA/ADA AND DRUG FREE
P. O. Box 52488, Tulsa, OK 74152 (918) 582-2100 FAX (918) 599-7266 APPLICATION FOR EMPLOYMENT PLEASE PRINT OR TYPE NAME (FIRST, MIDDLE, LAST SOCIAL SECURITY NO.) PRESENT ADDRESS (STREET, CITY, STATE &
More informationV E H I C L E U S E POL I C I E S AND PROC E D U R E S LAWRENCE UNIVERSITY
V E H I C L E U S E POL I C I E S AND PROC E D U R E S LAWRENCE UNIVERSITY Vehicle Policies and Procedures The goal of this document is to ensure the safety of Lawrence University employees and students
More informationDESCRIPTION OF OPERATIONS. LIABILITY COVERAGE Complete for desired coverages by indicating limits of insurance.
Special Types Application COLUMBIA INSURANCE COMPANY NATIONAL FIRE & MARINE INSURANCE COMPANY NATIONAL INDEMNITY COMPANY NATIONAL INDEMNITY COMPANY OF MID-AMERICA NATIONAL INDEMNITY COMPANY OF THE SOUTH
More informationOwner Operator Application
Owner Operator Application Name: (first) (middle) (last) Current Address: (street /city) (state, zip) (how long?) Previous Addresses: (street /city) (state, zip) (how long?) (street /city) (state, zip)
More informationBell Logistics Inc. Page 1 Bell Logistics, Inc. P.O. Box Old US 35 East Chillicothe, OH 45601
Bell Logistics Inc. Page 1 Bell Logistics, Inc. P.O. Box 91 27311 Old US 35 East Chillicothe, OH 45601 In compliance with Federal and State Equal Opportunity Laws, qualified applicants are considered for
More informationAlamo Pressure Pumping, LLC
Driver Information Sheet Answer all questions PLEASE PRINT CLEARLY PLEASE SELECT ONE OF THE FOLLOWING: Company Driver Owner Operator Date of application: S.S. # First Middle Last Street State Zip Country
More informationApplication for Rental Autos & Trucks B Short Term
Application for Rental Autos & Trucks B Short Term (Hour, Day or Week) Policy Term From: To 1. Name of Applicant 2. a. Address of Applicant (Number) (Street) (City) (County) (State) (Zip Code) b. Address
More informationAPPLICATION FOR EMPLOYMENT
SSN TOWING & STORAGE 3565 W. Columbus, Chicago, IL 60652 APPLICATION FOR EMPLOYMENT Name: FIRST-MIDDLE-LAST (AS IT APPEARS ON SOCIAL SECURITY CARD) SOCIAL SECURITY NO. TODAY'S DATE FORMER NAME HOME (AREA
More informationSpecial Types Application
Special Types Application 1. Name (and "dba") Individual/Proprietorship Partnership Corporation Other Policy Term From: To Business Phone Number 2. Mailing Address City State Zip 3. Premises Address City
More informationRECEIPT / ACCEPTANCE FORM HUNTSMAN INTERNATIONAL LLC ( Huntsman ) Bulk and Packed Motor Carrier Pick-Up and Delivery Policy
RECEIPT / ACCEPTANCE FORM HUNTSMAN INTERNATIONAL LLC ( Huntsman ) Bulk and Packed Motor Carrier Pick-Up and Delivery Policy EMAIL: huntsman_pup@huntsman.com For a current copy of the Bulk and Packed Motor
More informationCollision Reporting, Investigation, and Analysis
In this procedure, a collision is defined as any occurrence involving a motor vehicle driven by an employee on company business which results in death, injury, or property damage, unless the vehicle is
More informationHeartland Cooperative Services Job Application. Name: Last First Middle. Address Street. City State Zip Code Phone. Position Applied For
Heartland Cooperative Services Job Application Name: Last First Middle Address Street City State Zip Code Phone Position Applied For Days available for work Times available Special training or skills (languages,
More informationPropane and Fuel Oil Dealers Supplemental
Propane and Fuel Oil Dealers Supplemental Applicant Name: Requested Effective Date:_ Insured s Website: Section I Summary of Operations Please provide a narrative of the Insureds operations (Include all
More informationApplication for Rental Autos & Trucks B Short Term
Application for Rental Autos & Trucks B Short Term (Hour, Day or Week) NATIONAL INDEMNITY COMPANY OF THE SOUTH NATIONAL LIABILITY & FIRE INSURANCE COMPANY Administrative Office - Omaha, Nebraska Policy
More informationApplication for Rental Autos & Trucks Short Term
Application for Rental Autos & Trucks Short Term (Hour, Day or Week) National Fire & Marine Insurance Company National Indemnity Company of the South National Liability & Fire Insurance Company Policy
More informationDRIVER S EMPLOYMENT APPLICATION Highway 60 West Lewisport, KY 42351
DRIVER S EMPLOYMENT APPLICATION 9355 Highway 60 West Lewisport, KY 42351 (Answer all questions completely. If a question does not apply, respond to the question by indicating N/A Please PRINT LEGIBLY)
More informationAPPLICATION FOR QUALIFICATION
Employee ID: PO Box 930 224 4 th Street NW, Suite 8 Devils Lake, ND 58301 phone: 701.662.6300 fax: 701.662.9296 email: employment@topshelfenergy.com APPLICATION FOR QUALIFICATION COMPLETE ALL INFORMATION
More information