Page 1 DRIVER APPLICATION Last Name First Name Middle Initial P.O. Box 638 - Abbeville, AL 36310 www.greenbushlogistics.com Referred by
Page 2 DRIVER APPLICATION Greenbush Logistics, Inc. PO Box 638 Abbeville, AL 36310 o Abbeville, AL o Irvington, AL o Conyers, GA o Lake Panasoffkee, FL o Rocky Mount, VA o o Tuscumbia, AL o Glenwood, AR o Jesup, GA o Columbus, TX o Hagerstown, MD o Mt. Pleasant, TX o Brookhaven, MS o Buckner, MO o Mansura, LA o Fombell, PA please read carefully PRInt clearly Answer all questions greenbush logistics, inc. is an equal opportunity employer dedicated to non-discrimination in employment. Greenbush logistics, inc. selects the best qualified individuals for the job based on jobrelated qualifications regardless of race, age (40+), color, religion, sex, national origin, ancestry, marital status, sexual preference, disability or any other status protected by applicable law. Date Completed Name in Full Address (LAST) (FIRST) (MIDDLE) (NUMBER & STREET) (CITY) (STATE & ZIP CODE) How long have you lived at this address? How long have you lived in this area? ADDRESS FOR PAST THREE YEARS (Attach Sheet if more (STREET) (CITY) (STATE & ZIP CODE) space is needed.) (STREET) (CITY) (STATE & ZIP CODE) How long? How long? Applying Full-Time o Date Number of Years Salary for job as: Part-Time o Available Experience Expected Telephone Number Social Security No. PERSONAL INFORMATION Male o State your age Are you a U.S. Citizen or legally authorized to work in the U.S.? o yes* Female o if you are under 21 o no * Upon employment you will be required to provide identification and proof of citizenship or authorization to work in the U.S. Do you have any Relatives o yes If yes, give names, Employed by this Company? o no relationship and position Have you ever worked for this Company before? where? When? Position held? Reason for leaving? Have you ever o yes Have you ever been o yes If Yes explain been bonded? o no refused Bond? o no Have you ever been convicted of a DUI/DWI o yes o no Have you ever been convicted o yes* If Yes explain o Misdemeanor of a crime? (omit traffic violations) o no Date: o Felony * Conviction of a crime is not automatic bar to employment. All circumstances will be considered. EDUCATION SCHOOLS DATES ATTENDED NAME OF SCHOOL ADDRESS GRADUATE OR DEGREE? FROM TO High School College or University Business or Technical Truck Driving School
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URGENT REQUEST FOR D.O.T. EMPLOYMENT INFORMATION Page 5 Employment and Controlled Substance Inquiry to Previous Employers I authorize all my previous employers to release all information concerning my employment to Greenbush Logistics, Inc. (and its authorized agents) in connection with my application for employment. All parties involved shall not be held liable for the information that they furnish. Printed Name Driver SSN * Driver Signature Date To: Phone: Company: Fax: Date: Part A Information to be supplied by previous employer per 4 CFR Part 391.23 (a1) and (e). Applicant lists dates of employment as: From: To: 1. Actual Dates: From: To: 2. What type of work did the applicant do? Driver Dock Mechanic Other 3. Type of driver: Company O/O Lease/Purchase Trainee Other 4. Areas of operation: Local Regional OTR Other 5. Type of equipment: Straight Truck Tractor Trailer Twin Trailer Bus Other 6. Type of trailer: Flatbed Van Refrigerated Tank Other 7. Reason for leaving? Resigned Laid off Terminated Other 8. Eligible for Rehire: Yes No Upon Review Don t Rehire Other 9. Number of accidents? (Provide as much detailed information as possible) Date Description of Accident Preventable Non- Preventable DOT Reportable Part B 1. Was applicant subject to Federal Motor Carrier Safety Regulations while in your employ? Yes No 2. Was job designated as a safety sensitive function in any DOT regulated mode subject to alcohol and controlled substances testing requirements as required by 49 CFR part 40? Yes No Part C In Accordance with Part 391.23(e): 1. Has this person ever tested positive for a controlled substance while in your employment? Yes No 2. Has this person ever had an alcohol test BAC of.04 or greater while in your employment? Yes No 3. Has this person ever refused a required test for drugs or alcohol (including adulterated or substituted sample)? Yes No 4. Has this person had any other violations of DOT agency drug or alcohol testing regulations? Yes No 5. Did a previous employer report a drug and alcohol rule violation to you? Yes No 6. Within the last three (3) years, has this person tested positive or refused any drug or alcohol test conducted under the authority of your company, independent of the DOT or FMCSA requirements (Company Policy Test)? Yes No NOTE: Previous employer, if answered YES to any of the items in Part C you must also transmit copy/copies of the appropriate documentation (e.g., SAP reports, follow-up testing record, CCFs, etc.). SAP name: Phone number: Address: City: State: Zip: Completed By: Contact Number: Thank You! Please fax back to: @ (334) 585-7079
Page 6 Greenbush Logistics, Inc. PO Box 638 Abbeville, AL 36310 NON-DRIVING EMPLOYMENT VERIFICATION to: company: fax: the person below has authorized you to release details of his/her previous employment in accordance with department of transportation regulations: name: social security #: * applicant s signature: date: your type of business: applicant was employed as: were they? q full time q part time dates of employment: to any accidents or injuries? q yes q NO If so, please describe: date type preventable? reason this person left your company: would you rehire this person? does your company have a drug-free workplace policy? this form was completed by date thank you for your assistance please fax this completed form back to at (334) 585-7079 please call us at if you have any questions.
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* V. Driver s Signature: Date: Page 8 EMERGENCY CONTACT INFORMATION It is important for us to be able to reach someone in the event of an emergency. Please provide the names and telephone numbers of three people (other than your residence number) we can contact if an emergency should arise. Please print Name: Phone: ( ) Address: City, State, Zip:
NOTICE OF DRUG AND ALCOHOL TESTING In order to achieve the highest possible degree of safety in the public interest, and in accordance with Federal Guidelines, (1) All applicants for employment will undergo urinalysis screening for drug use as part of their pre-employment physical examination; (2) A drug use screen at time of re-certification; and (3) A drug and/or alcohol use test at other times as deemed necessary by management. Refusal to submit to a drug/alcohol test will be construed to be a voluntary resignation from employment. Results of the test will be used in determining an individual s employment status with the company. Upon hiring, you will be placed in a random testing pool for alcohol and drugs. Page 9 1. You will be pre-employment tested for the following a. Marijuana c. Opiates e. Phencyclidine (PCP) and must have a negative result prior to dispatch. b. Cocaine d. Amphetamines 2. Positive test results and refusals to test will be kept on file for five years and results will be given to persons/companies with proper authorization. 3. Use of alcohol per company policy will not be tolerated. 4. If you are brought to our terminal for employment processing at our Company s expense, and you test positive, we will stop paying your expenses at that time. 5. Anyone who claims to have a job related injury or accident may be drug/alcohol tested as part of initial medical treatment. Such testing may exceed the minimum standards set by D.O.T. 6. We also test for random, reasonable suspicion and post accidents per company policy and federal guidelines. I understand that my employment medical examination will include a urinalysis and that, in addition to routine testing, my urine specimen will be screened for drugs including, but not limited to, Cannabinoids (Marijuana), Amphetamines, Cocaine, Opiates, and PCP. I affirm that I have not taken any drugs or medicines within the last two (2) weeks, except (List medicines you are presently taking.) If none, so state * Signed: Applicant/Employee (must be signed and dated) Date ADDENDUM TO EMPLOYMENT APPLICATION As a prospective employer, we must ask any applicant for a driving position with our company whether he/she has tested positive, or refused to test, on any pre-employment drug or alcohol test administered by an employer to which the applicant applied for, but did not obtain, safety-sensitive transportation work (driving a commercial motor vehicle) during the past three years. q q Yes, I have tested positive for drugs/alcohol, or refused to take a pre-employment drug/alcohol test in the three years preceding the date of this application. No, I have not tested positive for drugs/alcohol, or refused to take a pre-employment drug/alcohol test in the three years preceding the date of this application. DOT regulations prohibit our utilizing you to perform a safety-sensitive function (driving a commercial motor vehicle) if you admit that you had a positive test, or a refusal to test, until and unless you provide documents showing successful completion of the return-to-duty process in accordance with DOT regulations. This certifies that I completed this addendum to the employment application, and that all information therein is true and complete to the best of my knowledge. I also understand that misrepresentation of information or facts will result in my rejection or dismissal. I hereby acknowledge that I have read and understand the statement above. * Applicant Signature Date
Page 10 DRUG SCREENING CONSENT and RELEASE FORM As an applicant for employment with Greenbush Logistics, Inc. (GLI), I understand that as a condition of my employment I must provide a bodily sample of urine, saliva or breathed air, which will be tested for the presence of drugs and/or alcohol. I have received notification and understand that a drug and/or alcohol screen test is a required part of GLI s application process and will be used for the purpose of evaluating me for employment. Accordingly, I agree to this requirement and authorize GLI and/or any doctor or medical professional, clinic, laboratory, or medical facility designated by GLI to collect from me one or more urine, saliva, or breathed air samples for this purpose. So that the tests will be valid, I agree not to intentionally adulterate, contaminate, dilute, or otherwise tamper with my sample(s). I hereby authorize GLI s Medical Review Officer to receive my drug and/or alcohol test results directly from the testing laboratory administering the drug and/or alcohol test on behalf of GLI, and I further authorize the Medical Review Officer to review and, if necessary, make the final determination of said results. I further consent to the release of the test results to GLI. I authorize and release GLI to forever use the results of any test as is necessary in any proceeding before any state or federal agency or court of competent jurisdiction related to any disciplinary measures that may be taken as a result of such test results. I further agree to release and hold harmless GLI, its subsidiaries, affiliates, officers, agents, representatives, employees, and its collection sites, laboratories, and agents from any liability arising in whole or in part out of the collection of specimens, testing, and use of the results of said testing in connection with the consideration of my employment. If employed, I consent to post-accident, random testing, and reasonable suspicion testing in accordance with GLI s Drug and Alcohol Policy in accordance with my consent, authorization, and agreement above. I agree that a reproduced copy of this form shall have the same force and effect as the original. I have carefully read the foregoing and fully understand it contents. Full Name Printed Social Security Number * Applicant s Signature Date Witness Printed Name Witness Signature Date
Page 11 CONSUMER REPORT AUTHORIZATION AND RELEASE FORM To Whom It May Concern: I have been given notification that a consumer report and past drug/alcohol testing information will be requested and used for the purpose of evaluating me for employment at Greenbush Logistics, Inc. (GLI) and, if hired, for promotion, reassignment or retention as an employee at GLI. Thus, I hereby authorize and request any present or former employer, school, police department, financial institution, agency or other persons having personal knowledge about me, to furnish GLI and/or its agents with any and all information in their possession regarding me in connection with an application for employment, including consumer report information that may include an independent investigation of my background, references, character, past employment, education, credit history, motor vehicle records, criminal or police records, including those maintained by both public and private organizations, and all public records for the purpose of confirming the information contained on my Application and/or obtaining other information which may be material to my qualifications for employment. I agree that a photocopy of this authorization has the same authority and effect as the original, and I specifically waive any written notice from any present or former employer who may provide information based upon this authorized request. I also understand that this authorization is a required part of GLI s application process. I release and hold harmless GLI and/or its agents and any person or entity that provides information pursuant to this authorization from any and all liabilities, claims or law suits in regard to the information obtained from any and all of the above referenced sources used. The following is my true and complete legal name and all information is true and correct to the best of my knowledge: Full Name Printed Maiden Name or Other Name(s) Used Date of Birth Social Security Number Driver s License Number/State of License * Signature Date NOTE: The above information is required for identification purposes only, and is in no manner used as qualifications for employment. GLI is an Equal Opportunity Employer, and does not discriminate on the basis of Sex, Race, Religion, Age (40 and over), Disability or National Origin.
Page 12 IMPORTANT NOTICE REGARDING BACKGROUND REPORTS FROM THE PSP Online Service In connection with your application for commercial driver employment with Greenbush Logistics, Inc. (GLI), it is necessary that we obtain information regarding your driving history from the Federal Motor Carrier Safety Administration of the Department of Transportation (FMCSA-DOT). This is called their Pre-employment Screening Program (PSP) and it is part of their CSA 2010 initiative. To do this we must access this information through a consumer reporting agency called NIC Technologies (NICT). All information in the NICT data base is supplied to them by the FMCSA. The information requested will be used for pre-employment screening purposes only. If GLI uses any information it obtains from the PSP Online Service in a decision not to hire you, GLI will provide you a copy of the report upon which this decision was made or you can request a free copy from FMCSA-DOT. You have a right to dispute incomplete or inaccurate information in the Records by visiting https://dataqs.fmcsa.dot.gov. Please note that ONLY FMCSA-DOT is authorized to receive proposed corrections to database information and determine if the information should be corrected. GLI cannot obtain background reports from the PSP Online Service or other sources regarding you unless you consent in writing. If you agree that GLI may obtain such background reports, please read the following and sign below. I authorize Greenbush Logistics, Inc. to contact PSP Online Service to 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. In addition, I consent to the release of any additional reference check or background investigation of my suitability for employment. In exchange for Greenbush Logistics 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 Greenbush Logistics, Inc. 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 Greenbush Logistics, Inc. 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 Notice Regarding Background Reports provided to me by Greenbush Logistics, Inc. and I understand that if I sign this consent form, Greenbush Logistics, Inc. and/or any entity it retains to obtain such background reports may obtain reports of my driving history from the PSP Online Service. I hereby authorize Greenbush Logistics, Inc. and its employees, agents, and affiliates to obtain the information authorized above. Printed Name: Date: Applicant s Signature: Date:
To Be Read and Signed by Applicant Page 13 I understand that the information in this application will be used and that prior employers will be contacted for purposes of investigation as required by section 391.23 of the Federal Motor Carrier Safety Regulations. I hereby state that all the information that I provided on this Application or any other document submitted in connection with my employment, and in any interview, are true and correct. I have withheld nothing that would, if disclosed, affect this Application unfavorably. I understand that any information falsely provided or improperly withheld will result in the rejection of my Application, and that if I am employed and any information is later found to be false in any respect or if I have omitted material information, my employment will be terminated for dishonesty. Applicant is hereby advised that he/she has the right to review the information obtained from previous employers, to correct any errors in such information and to rebut any perceived incorrect information. Within 5 days of receiving a written request from the applicant, Greenbush Logistics, Inc. will provide applicant with the records received from his/her previous employer(s). If such request is made before the investigation information is received, GLI will provide such information within 5 days of being received. It is agreed and understood that Greenbush Logistics, Inc. or its agents may investigate or ascertain any and all information as it relates to the applicant s background, and applicant releases employers and persons herein from all liability for any damages on account of furnishing such information to Greenbush Logistics, Inc. The applicant agrees to furnish such additional information and complete such examinations as may be required to complete his/her employment file. It is agreed and understood that this application for employment in no way obligates Greenbush Logistics, Inc. to employ the applicant. It is agreed and understood that if hired, the employee will be on a probationary period of 90 calendar days, during which time he/she may be discharged without recourse. If hired, I agree as follows: My employment with Greenbush Logistics is terminable at will, is for no definite period, and my employment may be terminated by Greenbush Logistics or me at any time and for any reason whatsoever, with or without good cause. No implied, oral or written agreements contrary to the express language of this Agreement are valid unless they are in writing signed by the President of Greenbush Logistics. No supervisor or representative of Greenbush Logistics, other than the President of Greenbush Logistics, has the authority to make any agreements to the foregoing. This Agreement is the entire agreement between Greenbush Logistics and the employee regarding the right of Greenbush Logistics or the employee to terminate employment, and this Agreement takes the place of all prior agreements, representations, and understandings of the employee and Greenbush Logistics. I also understand that when I leave, my final pay will not be received until I have submitted ALL necessary paperwork and returned ALL company property. Greenbush Logistics, Inc. is an Equal Opportunity Employer in accordance with the Civil Rights Act of 1964 which prohibits discrimination in employment because of race, color, religion, sex, or national origin. By signature below, I certify 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. I hereby acknowledge that I have read and understand the above statements. * Applicant s Signature Date (MUST BE SIGNED AND DATED)
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