1. Company Information
It is the policy of the company listed above to provide equal employment opportunities to all applicants and employees without regard to any legally protected status such as race, color, religion, gender, sexual orientation, national origin, age, disability or veteran status.
2. Applicant Information
Years at Current Address:
Does this cover your last seven years of residency?
Years at Second Address:
Years at Third Address:
Day Time Telephone number:
Cellular Telephone Number:
Please provide your Social Security Number:
Would you like to provide your Birthdate:
Are you at least 18 Years of Age?:
3. Emergency Contact Information
Emergency Contact Name:
Emergency Contact relationship:
Emergency Contact Address:
Emergency Contact Primary Telephone number:
Emergency Contact Secondary Telephone number:
4. Employment Type Desired
What position are you applying for?
Full time or Part-time desired?
Were you referred by someone and if so, Who:
Have you worked for this company before?
If you have worked for this Company Before, Why did you leave?
Date of employment from:
Date of employment to:
How will you get to work?
Are you willing to work any shift, including nights and weekends?
Please explain any limitations:
If Applicable, are you willing to work Overtime?
If Offered Employment, when would you be able to begin work?
Are you able to perform the essential function of the job position you seek with or without reasonable accommodation?
What reasonable accommodation, if any, would you request?
5. Salary Desired
If Hired, are you able to submit proof that you are legally eligible for employment in the united states?
6. Criminal History
THE EXISTENCE OF A CRIMINAL RECORD DOES NOT CONSTITUTE AN AUTOMATIC BAR TO EMPLOYMENT UNLESS RELEVANT TO THE TYPE OF EMPLOYMENT. ALL APPLICANTS WILL HAVE A CRIMINAL BACK GROUND CHECK PERFORMED.
Do you live in a State that prohibits an employer asking about your criminal history?
Have you ever been convicted of a Crime:
If yes, Please Explain:
7. Skills and Training
Typing/Keyboarding Experience Level:
Microsoft Excel Experience Level:
Microsoft Word Experience Level:
Microsoft Powerpoint Experience Level:
Accounting/Bookkeeping Experience Level:
Answering Telephones Experience Level:
Filing Experience Level:
Customer Service Experience Level:
Other Skill Types:
8. Applicants Education and Training
Last School Attended:
Last School Address:
Did you receive a Degree:
Degree Type Received:
Please indicate any current professional licenses or certifications that you hold:
Please indicate any Awards, Honors or Special Achievements:
9. Military Service
Are you or were you a member of the Military?
Which Military Branch did you serve in?
Please list any specialized Training:
10. Previous Employment
DRIVER Applicants that desire to drive in intrastate/interstate commerce must provide the following information on all employers during the previous three years. You must give the same information for all employers you have driven a commercial motor vehicle for the seven years prior to the initial three years (total of ten years employment record).
#1 First Previous Employer or Current employer Information:
Years with this engagement:
Were you subject to the FMCSR's (drug and alcohol testing) While employed by this previous employer?
Job was 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?
Would you like to provide a FAX number, Email address or both:
Company Fax #:
Supervisor or HR Email:
Company Phone Number:
Reason for Leaving:
Beginning Date of Employment:
Ending Date of Employment:
Do you intend to remain employed with this employer:
Rate of Pay (Per Hour):
Does this Complete your ten year history?
#2 Previous Employer Information:
#3 Previous Employer Information:
#4 Previous Employer Information:
Did you drive any commercial vehicles for any company in the last ten years that you were unable to list above?
Did you drive any Commercial Vehicles for any company in the last ten years that you were unable to list above?
Please explain any gaps of employment or enter "NONE' if there are no gaps in dates from one employer to the next.
List any two non-relatives who would be willing to provide reference for you.
Name of Reference:
Address of Reference:
Telephone Number of Reference:
Relationship to Reference:
12. Driver License, Experience and Violations or Collisions
DRIVER APPLICANTS: Please list all states you have been licensed in within the last FIVE years. Is this the only License you have held within the last five years?
Driver License Number:
State of Issue:
DRIVER APPLICANTS: Please list all states you have been licensed in within the last FIVE years. Does this complete the licenses you have held in the last five years?
Section 383.21 FMCSR states "No person who operates a commercial motor vehicle shall at any time have more than one driver's license". I certify I do not have more than one motor vehicle license, the information for which is listed here.
DOT Driver Date of Birth:
DOT Applicants are required to provide this information.
Driver License Expiration Date:
Driver License Class:
Current State of Issue:
What types of CMV have you experience operating:
Approximately how many miles were driven in a Motor Coach?
Enter dates (MMYYY to MMYYY) that you operated motorcoaches:
Approximately how many miles were driven in a Mini Coach:
Enter dates (MMYYY to MMYYY) that you operated mini coaches:
Approximately how many miles were driven in a Semi Truck:
Enter dates (MMYYY to MMYYY) that you operated semi trucks:
Approximately how many miles were driven in a Dump or Box Truck?
Enter dates (MMYYY to MMYYY) that you operated dump or box trucks:
Please explain other equipment type:
Please enter all Accidents within the last three years preceding the date of application. These will be verified with your Motor Vehicle Record as well as the PSP Report. If you have NONE, please Select None.
How many Accidents have you had in the last three years?
Nature of First Accident:
Date of Occurence:
Were Fatalities or Personal Injuries Sustained?
Was this a Reportable DOT accident?
Nature of Second Accident:
Nature of Third Accident:
Nature of Fourth Accident:
Please enter all Violations of motor vehicle laws or ordinances (other than violations involving only parking) of which the applicant was convicted or forfeited bond or collateral during the last three years preceding the date of application. These will be verified with your Motor Vehicle Record as well as the PSP Report. If you have NONE, please select None.
Nature of First Violation:
Date of occurrence:
Was this in a Commercial Motor Vehicle?
Nature of Second Violation:
Nature of Third Violation:
Have you ever been denied a license, permit or privilege to operate a motor vehicle?
If Yes, please Explain:
Has any license, permit or privilege been suspended or revoked?
If yes, Please explain:
Have you ever tested positive on a drug or alcohol test?
If yes, please explain:
49 CFR 40.25(j) -During the past three (3) years have you tested positive on a pre-employment alcohol or drug test administered by Employer to which you applied for but did not obtain. a safety sensitive transportation work covered by Department of Transportation (DOT) drug and alcohol testing rules?
If you answered yes to the above question, have you successfully completed the return-to-duty process?
If yes, you must provide documentation before any Safety-sensitive transportation function is performed. How will you deliver this information?
During the past three (3) years have you refused to test on a Pre-employment alcohol or drug test administered by an Employer to which you applied for but did not obtain a safety sensitive transportation work covered by the Department of Transportation (DOT) drug and alcohol testing roles?
If yes, please explain.
All driver applicants will be required to submit to and pass a drug and alcohol test as a condition of employment. Job applicants who are denied employment because of a positive test may reapply for employment after 6 months. Offers of employment are made upon passing the Company's review, including the drug and alcohol test. Driver applicants who have received firm employment offers should be cautioned against giving notice to their current place of employment until after medical clearance has been received. In compliance with DOT regulations, your name will be added to the Random Selection Program for drug and alcohol testing for continued employment.
13. Notice to All Applicants:
I certify that the information provided on this application is truthful and accurate. I understand that providing false or misleading information will be the basis for rejection of my application, or if employment commences, immediate termination.
I authorize to contact former employers and educational organizations regarding my employment and education. I authorize my former employers and educational organizations to fully and freely communicate information regarding my previous employment, attendance, and grades. I authorize those persons designated as references to fully and freely communicate information regarding my previous employment and education.
If an employment relationship is created, I understand that unless I am offered a specific written contract of employment signed on behalf of the organization by its CEO, the employment relationship will be "at-will." In other words, the relationship will be entirely voluntary in nature, and either I or my employer will be able to terminate the employment relationship at any time and without cause. With appropriate notice, I will have the full and complete discretion to end the employment relationship when I choose and for reasons of my choice. Similarly, my employer will have the right. Moreover, no agent, representative, or employee of , except in a specific written contract of employment signed on behalf of the organization by its CEO, has the power to alter or vary the voluntary nature of the employment relationship.
The Company may not require a pre-employment medical examination, but does reserve the right to require drug testing and a medical examination after an offer of employment is made to the applicant. All offers of employment are conditional upon the passing of a drug test for the purpose of detecting the illegal use of drugs. Also, if an employment offer is made, you will be asked to answer certain medical questions. Medical examinations and answers to medical inquiries will be maintained on separate forms, and will be treated as confidential medical records. An applicant will not be excluded from employment unless they have medical conditions that prohibit their ability to perform the essential job functions of the position they desire within this company. The Company will make reasonable accommodations to qualified individuals with disabilities in the application process and, if hired, allow qualified individuals with disabilities to perform essential job functions. Written job descriptions are available and will be furnished to applicants upon request. The Company may use the information contained in this application and may contact your former employer(s) for the purpose of investigating your safety performance history information as required by the Federal Motor Safety Regulations (49 CFR 391.23 (d) and (3). Pursuant to 49 CFR 391.23 (i), you have the following rights regarding the investigative information that is provided to The Company by your previous employer(s):
14. Fair Credit reporting Act Disclosure Statement
In accordance with the provisions of the Fair Credit Reporting Act (Public La 91-508) as amended by the Consumer Credit Reporting Act of 1996. I have been informed the Company will procure a motor vehicle report (MVR), criminal background check and reference checks, all of which are defined as a consumer report regarding my driving and background record to determine my suitability for work at the Company. I understand that I have the rights to request, in writing, information pertaining to the nature and scope of the inquiry and a written summary of my rights under the Fair Credit Reporting Act. I understand that I may have additional rights under applicable state and federal laws. I hereby authorize the Company to obtain this information and release and hold harmless any person, firm, or entity that discloses such information in accordance with this authorization. This authorization shall remain on file and shall serve as ongoing authorization for the Company to procure a motor vehicle report (MVR) and a criminal check which is defined as a consumer report at any time during my employment period. Any copy of this authorization shall have the same authority as the original.
15. Carefully review the following conditions
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.
Date of application:
If you have any questions regarding the conditions, you should ask for an explanation or clarification from the employment interviewer. Signify your understanding and specific acceptance of each condition by your signature in the space provided at the end of the conditions. I hereby authorize The Company to investigate any and all statements contained in this application. I hereby consent to The Company conducting any checks concerning my background which are deemed necessary, advisable, or helpful by The Company (except contacting my current employer prior to hiring, unless permission is granted above). I understand that if hired, I will receive a copy of The Company rules and regulations and the Company's policies including its drug/alcohol policy. I will read and understand the rules, regulations, and policies; and I acknowledge that I will be required to abide by them. I understand that if hired, I will be required to submit to a drug test as part of this application procedure. I hereby consent to that drug test, agree to cooperate fully with that drug test, and waive any and all objections I might otherwise have to such drug testing. I understand that if I am offered employment, it may be contingent upon passing a medical examination. If so, I hereby consent to such medical examination, and will fully cooperate with any required examination. I understand and agree that if this application results in employment, my employment can be terminated with or without cause and with or without notice, at any time, at the option of either The Company or myself. I understand that no manager or representative of The Company as any authority to enter into any agreement for employment for any specified period of time or to make any agreement contrary to the foregoing. I certify and guarantee that all statements made on this application are true and complete to the best of my knowledge and without mental reservations. I understand that falsification of this application may result in my not being considered for employment or, in the event I become employed by in my dismissal, regardless of when such falsification is discovered. 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.
I certify that the information provided on this application is truthful and accurately reflects my employment history covering the last ten years. I understand that providing false or misleading information will be the basis for rejection of my application, or if employment commences, immediate termination.
APPLICANT AUTHORIZATION TO OBTAIN INVESTIGATIVE BACKGROUND REPORT In connection with my application for employment or promotion or other job change, I hereby instruct and authorize (the "Company") to obtain an INVESTIGATIVE CONSUMER REPORT on me that will include information as to my character, general reputation , personal characteristics and mode of living. This report may reveal information about my work habits, including oral assessments of my job performance, experiences and abilities, along with reasons for termination of past employment. Such a report may be requested by the Company or on behalf of the Company. Further, I understand and agree that the Company and/or the below-named Consumer Reporting Agency may request information from various federal, state, and other agencies, including public and private sources which maintain records concerning my past activities relating to my driving record, credit history , criminal record, civil matters , previous employment , educational background and professional licensing, if any. This report will be ordered from the below-named Consumer Reporting Agency:
Social Security Number:
Date of Birth:
Would you like to provide your ethnicity information at this time:
Address you have lived at for the last seven years:
Does this cover your last three years of residency?
This is written notice from the Company that an investigative consumer report is being obtained from a consumer reporting agency (CRA) for employment purposes. The undersigned applicant hereby instructs, authorizes and requests any present or former employer , school , police department , financial institution , division of motor vehicles , or other persons or agencies having personal knowledge about the undersigned applicant to furnish the above-named Consumer Reporting Agency with any and all information in their possession regarding the undersigned applicant, in connection with an application for employment. The undersigned applicant hereby instructs, authorizes and requests that a photocopy of this authorization be accepted with the same authority as the original.
Under the federal Fair Credit Reporting Act (FCRA) and other applicable state law, you have certain rights with regard to consumer reports obtained for employment purposes including , upon request , disclosure of information on you in the reporting agency's file at the time of the request, including the identification of persons who have procured a consumer report concerning you, and reasonable opportunity to respond to any information in the report that is disputed by you. The FCRA, 15 U.S.C. 1681, is designed to promote accuracy, fairness , and privacy of information in the files of every "consumer reporting agency " (CRA). You can obtain a copy of any investigative consumer report obtained by Association Background Checks, Inc. Request for disclosure of the reporting agency's file should be made in writing within a 60 day time period to: Association Background Checks, 1200 South Outer Road, Blue Springs, MO 64015 | Tel. 816-463-2952 | Fax. 816-224-9699.
If a consumer investigative report is obtained and an adverse decision is made affecting your employment, the Company will provide to you, before making the adverse decision , a copy of the investigative consumer report and a copy of the Federal Trade Commission Publication , A Summary of Your Rights Under the Fair Credit Reporting Act. The undersigned applicant hereby acknowledges that he/she (i) has read or has had read to him/her the above authorization and disclosures, (ii) has understood it, (iii) had the opportunity to consult with and discuss this form with his/her attorney prior to signing this document, and (iv) agrees to be fully bound by it.
EMPLOYER CERTIFICATION TO CONSUMER REPORTING AGENCY; By submitting this order to the above-referenced Consumer Reporting Agency, the undersigned Company and individual agent signing on behalf of the Company expressly certifies to the above-referenced Consumer Reporting Agency (i) that any reports procured related hereto will be used for employment screening purposes only pursuant to FCRA Section 604(a)(3)(B) ; (ii) that prior to taking any adverse action , based in whole or in part upon said report(s), the Company will provide the applicant a copy of the report(s) and a copy of the publication, A Summary of Your Rights Under the Fair Credit Reporting Act; and (iii) that said report(s) will not be used in violation of any applicable Federal or State law or regulation including those specifically governing equal employment opportunity .
Employer or Authorized Representative Signature: __________________________
I hereby Authorize: Association Background Checks, 1200 South Outer Road, Blue Springs, MO 64015 | Tel. 816-463-2952 | Fax. 816-224-9699 to run a criminal background check at this time.
This form is for authorization to annually pull your MVR (motor vehicle record) for insurance purposes and review. This form exists in a secure environment, and the information is sent directly to the employer for review and storage in a secure environment.
DOL Eye Color:
Cellular Phone Number:
Idaho License Holders: Section 49-203 Idaho code prohibits the release of personal information contained in driver license records to unauthorized parties, without the express written consent of the individual the information pertains to. As an authorized requestor you may receive this information but you may not re-release or re-sell it.
Idaho Reference Number:
Type of record that will be requested can only be: EMPLOYMENT RECORD. Used to determine if a driver should be employed. Employers and their agents, prospective employers and their agents.
This form is for authorization to initially pull your MVR (motor vehicle record) for insurance purposes and review. This form exists in a secure environment, and the information is sent directly to the employer for review and storage in a secure environment. This will only be pulled if you have failed to provide the correct MVR form in a timely fashion and your application indicates your experience and skills dictate would like to pursue the employment opportunity.
Idaho License Holders: Section 49-203 Idaho code prohibits the release of personal information contained in driver license records to unauthorized parties, without the express written consent of the individual the information pertains to. As an authorized requestor you may receive this information but you may not re-release or re-sell it.
Type of record that will be requested can only be: COMPLETE RECORD. Used to determine if a driver should be employed. Employers and their agents, prospective employers and their agents.
THE BELOW DISCLOSURE AND AUTHORIZATION LANGUAGE IS FOR MANDATORY USE BY ALL ACCOUNT HOLDERS. THIS IS AN IMPORTANT DISCLOSURE REGARDING BACKGROUND REPORTS FROM THE PSP ONLINE SERVICE.
In connection with your application for employment with employer listed in the header above, it's employees, agents or contractors may obtain one or more reports regarding your driving, and safety inspection history from the Federal Motor Carrier Safety Administration (FMCSA).
Name of Applicant:
When the application for employment is submitted in person, if the Prospective Employer uses any information it obtains from FMCSA in a decision to not hire you or to make any other adverse employment decision regarding you, the Prospective Employer will provide you with a copy of the report upon which its decision was based and a written summary of your rights under the Fair Credit Reporting Act before taking any final adverse action. If any final adverse action is taken against you based upon your driving history or safety report, the Prospective Employer will notify you that the action has been taken and that the action was based in part or in whole on this report.
When the application for employment is submitted by mail, telephone, computer, or other similar means, if the Prospective Employer uses any information it obtains from FMCSA in a decision to not hire you or to make any other adverse employment decision regarding you, the Prospective Employer must provide you within three business days of taking adverse action oral, written or electronic notification: that adverse action has been taken based in whole or in part on information obtained from FMCSA; the name, address, and the toll free telephone number of FMCSA; that the FMCSA did not make the decision to take the adverse action and is unable to provide you the specific reasons why the adverse action was taken; and that you may, upon providing proper identification, request a free copy of the report and may dispute with the FMCSA the accuracy or completeness of any information or report. If you request a copy of a driver record from the Prospective Employer who procured the report, then, within 3 business days of receiving your request, together with proper identification, the Prospective Employer must send or provide to you a copy of your report and a summary of your rights under the Fair Credit Reporting Act.
Neither the Prospective Employer nor the FMCSA contractor supplying the crash and safety information has the capability to correct any safety data that appears to be incorrect. You may challenge the accuracy of the data by submitting a request to https://dataqs.fmcsa.dot.gov. If you challenge crash or inspection information reported by a State, FMCSA cannot change or correct this data. Your request will be forwarded by the DataQs system to the appropriate State for adjudication.
Any crash or inspection in which you were involved will display on your PSP report. Since the PSP report does not report, or assign, or imply fault, it will include all Commercial Motor Vehicle (CMV) crashes where you were a driver or co-driver and where those crashes were reported to FMCSA, regardless of fault. Similarly, all inspections, with or without violations, appear on the PSP report. State citations associated with Federal Motor Carrier Safety Regulations (FMCSR) violations that have been adjudicated by a court of law will also appear, and remain, on a PSP report.
If you agree that the Prospective Employer may obtain such background reports, please read the following and sign below: I authorize the employer listed in the header above to access the FMCSA Pre-Employment Screening Program (PSP) system to seek information regarding my commercial driving safety record and information regarding my safety inspection history. I understand that I am authorizing the release of safety performance information including crash data from the previous five (5) years and inspection history from the previous three (3) years. I understand and acknowledge that this release of information may assist the Prospective Employer to make a determination regarding my suitability as an employee. I further understand that neither the Prospective Employer nor the FMCSA contractor supplying the crash and safety information has the capability to correct any safety data that appears to be incorrect. I understand I may challenge the accuracy of the data by submitting a request to https://dataqs.fmcsa.dot.gov. If I challenge crash or inspection information reported by a State, FMCSA cannot change or correct this data. I understand my request will be forwarded by the DataQs system to the appropriate State for adjudication. I understand that any crash or inspection in which I was involved will display on my PSP report. Since the PSP report does not report, or assign, or imply fault, I acknowledge it will include all CMV crashes where I was a driver or co-driver and where those crashes were reported to FMCSA, regardless of fault. Similarly, I understand all inspections, with or without violations, will appear on my PSP report, and State citations associated with FMCSR violations that have been adjudicated by a court of law will also appear, and remain, on my PSP report. I have read the above Disclosure Regarding Background Reports provided to me by Prospective Employer and I understand that if I sign this Disclosure and Authorization, Prospective Employer may obtain a report of my crash and inspection history. I hereby authorize Prospective Employer and its employees, authorized agents, and/or affiliates to obtain the information authorized above.
The Prospective Employer cannot obtain background reports from FMCSA without your authorization.
Date of Authorization:
Name of Applicant:
I hereby authorize and its employees, authorized agents, and/or affiliates to obtain the information authorized above.
Name of license Holder:
MOTOR CARRIER INSTRUCTIONS: The requirements in Part 383 apply to every driver who operates in intrastate, interstate, or foreign commerce and operates a vehicle weighing 26,001 pounds or more, can transport more than 15 people, or transports hazardous materials that require placarding.
The requirements in Part 391 apply to every driver who operates in interstate commerce and operates a vehicle weighing 10,001 pounds or more, can transport more than 15 people, or transports hazardous materials that require placarding.
DRIVER REQUIREMENTS: Parts 383 and 391 of the Federal Motor Carrier Safety Regulations contain some requirements that you as a driver must comply with. These requirements are in effect as of July 1, 1987. They are as follows:
1) POSSESS ONLY ONE LICENSE:
You, as a commercial vehicle driver, may not possess more than one motor vehicle operator's license. If you have more than one license, keep the license from your state of residence and return the additional licenses to the states that issued them. DESTROYING a license does not close the record in the state that issued it; you must notify the state. If a multiple license has been lost, stolen, or destroyed, close your record by notifying the state of issuance that you no longer want to be licensed by that state.
2) NOTIFICATION OF LICENSE SUSPENSION, REVOCATION OR CANCELLATION:
Sections 391.15(b)(2) and 383.33 of the Federal Motor Carrier Safety Regulations require that you notify your employer the NEXT BUSINESS DAY of any revocation or suspension of your driver's license. In addition, Section 383.31 requires that any time you violate a state or local traffic law (other than parking), you must report it within 30 days to: 1) your employing motor carrier, and 2) the state that issued your license (If the violation occurs in a state other than the one which issued your license). The notification to both the employer and state must be in writing .
The following license is the only one I will possess:
Drivers License Number:
Driver License State of Issue:
Date of License Expiration:
Name on Driver License:
Applicants that desire to drive in intrastate/interstate commerce must provide the following information on ALL EMPLOYERS during the previous three years. Additionally, you must provide the same information for all employers you HAVE DRIVEN A COMMERCIAL MOTOR VEHICLE for for the seven years prior to the initial three years (total of ten years employment record for CDL drivers)
SECTION 1: To be completed by the applicant for submission to previous employer. All fields are required.
Requesting Company Name:
Applicant Email Address:
Previous Employer Manager:
Previous Employer Address:
Previous Employer Telephone:
Previous Employer FAX:
Previous Employer Email:
Employed to (enter current date if still employed):
Final hourly rate of Pay:
Were you subject to the Federal Motor Carrier Safety Regulations (FMCSRs) While employed by this employer?
Was the previous job position 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 49?
SECTION 2: To be completed by the applicant. As required by CFR 49 Part 391.23(c), we are forwarding this inquiry on the above named person who has made application to the above referenced company for employment as a commercial vehicle operator or mechanic. We respectfully request that you reply to this inquiry to the extent that your company policy allows, regarding this applicant. The applicant has signed the attached liability release for your records.
RELEASE of INFORMATION Form-49 CFR Part 40 Drug and Alcohol Testing: I hereby authorize release of information from my Department of Transportation regulated drug and alcohol testing records by my previous employer listed in Section 1, to the employer listed in the header section. This release is in accordance with DOT Regulation 49 CFR Part 40, Section 40.25. I understand that information to be released in Section 3 by my previous employer is limited to the following DOT regulated testing items.
Items to be released: Alcohol Tests with a result of 0.04 or higher, Verified positive drug tests, Refusals to be tested, Other violations of DOT agency drug and alcohol testing regulations, Information obtained from previous employers of a drug and alcohol rule violations, and Documentation, if any, of completion of the return-to-duty process following a rule violation.
SECTION 3: To be completed by previous Employer and transmitted by mail, please fax or email to the new employer. Fax, Mail or Email with information listed at top of page.
Did the employee have alcohol tests with a drug result of 0.04 or higher?
Did the employee have verified positive drug results?
Did the employee refuse to be tested?
Did the employee have other violations of DOT agency drug and alcohol testing rules?
Did a previous employer report a drug or alcohol rule violation to you?
If you answered yes to any of the above items, did the employee complete the return-to-duty process?
NOTE: If you answered yes to item 5, you MUST provide the previous employer's report. If you answered "yes" to item 6, you must also transmit the appropriate return-to-duty documentation
(e.g., SAP report(s), follow up testing record).
SECTION 4: To be completed by previous Employer
Employee was Employed From: _________________
Employee was Employed to: _____________________
Reason For leaving:__________________________________________________________
Number of DOT Recordable Accidents: __________________________________________
Number of non-DOT Recordable Accidents/Incidents:_______________________________
Was applicant's Drivers License ever suspended or revoked?
Was applicant's general conduct satisfactory?
Was there a history of absenteeism or tardiness on this applicant?
Did this applicant give adequate notice prior to leaving your employment?
It is a violation of our policy to release information other than that information provided here.
Federal law requires that DOT regulated employers respond in a timely manner to these requests. If a previous employer fails to respond to the request, it is the requirement of law that the potential or new employer submit documentation that a previous employer failed to respond to the CFR 49 Drug and Alcohol Request.
Employer representative completing form: __________________________________________
Date Completed: ___________
Telephone Number of Representative: ______________________
Title of Representative: _______________________________________________________
Attempt #1 Sent: ___________ Date: ____ / ____ / ______ Time____ : _____
Attempt #2 Sent: __________ Date: ____ / ____ / ______ Time____ : _____
Was there a history of absenteeism or tardiness on this applicant?
It is a violation of our policy to release information other than that information provided here.
It is a violation of our policy to release information other than that information provided here.
Did a previous employer report a drug or alcohol rule violation to you?
DRUG AND ALCOHOL ABUSE POLICY
STATEMENT OF PURPOSE AND POLICY
This document has been prepared for:
This individual is currently employed or applying for employment with:
On this Date:
Drivers are an extremely valuable resource for ’ business. Their health and safety is a serious company concern. Drug or alcohol use may pose a serious threat to driver health and safety. It is, therefore, the policy of the company to prevent substance use or abuse from having an adverse effect on our drivers. maintains that the work environment is safer and more productive without the presence of alcohol, illegal or inappropriate drugs in the body or on property. Furthermore, drivers have a right to work in an alcohol and drug-free environment and to work with drivers free from the effects of alcohol and drugs. Drivers who abuse alcohol or use drugs are a danger to themselves, their coworkers and the 's assets.
The adverse impact of substance abuse by drivers has been recognized by the federal government. The Federal Motor Carrier Safety Administration (FMCSA) has issued regulations which require the to implement a controlled substance testing program. will comply with these regulations and is committed to maintaining a drug-free workplace. All drivers are advised that remaining drug-free and medically qualified to drive are conditions of continued employment with the Company.
Specifically, it is the policy of the company that the use, sale, purchase, transfer, possession or presence in one's system of any controlled substance (except medically prescribed drugs) by any driver while on company premises, engaged in Company business, while operating Company equipment, or while under the authority of the company is strictly prohibited.
FMCSA states that mandatory testing must apply to every person who operates a commercial motor vehicle in interstate or intrastate commerce and is subject to the CDL licensing requirement.
The execution and enforcement of this policy will follow set procedures to screen body fluids (urinalysis), conduct breath testing, and/or search all driver applicants for alcohol and drug use, and those drivers suspected of violating this policy who are involved in a US Department of Transportation (DOT) reportable accident or who are periodically or randomly elected pursuant to these procedures. These procedures are designed not only to detect violations of this policy, but to ensure fairness to each driver. Every effort will be made to maintain the dignity of drivers or driver applicants involved. Disciplinary action will, however, be taken as necessary.
Neither the policy nor any of its terms are intended to create a contract of employment or to contain the terms of any contract of employment. is an employment at will company. retains the sole right to change, amend or modify any term or provision of this policy without notice. This policy is effective January 1, 2015, and will supersede all prior policies and statements relating to alcohol or drugs.
ADMINISTRATION GUIDE TO
ALCOHOL AND DRUG TESTING PROCEDURES
The purpose of this administrative guide is to set forth the procedures for the implementation of controlled substances and alcohol use and testing of driver applicants and current drivers pursuant to the Alcohol and Drug Abuse Policy. These procedures are intended as a guide only, and are in no way intended to alter any existing relationship between and any driver.
The alcohol and drug program administrator designated to monitor, facilitate, and answer questions pertaining to these procedures is: .
When interpreting or implementing these procedures, or the procedures required by he Federal Motor Carrier Safety Administration (FMCSA) controlled substance testing regulations the following definitions apply:
“Alcohol” means the intoxicating agent in beverage alcohol, ethyl alcohol, or other low molecular weight alcohols including methyl and isopropyl alcohol.
“Alcohol concentration (or content)” means the alcohol in a volume of breath expressed in terms of grams of alcohol per 210 liters of breath as indicated by an evidential breath test under this part.
“Collection site” means a place where individuals present themselves for the purpose of providing breath, body fluid, or tissue samples to be analyzed for specified controlled substances. This site must possess all necessary personnel, materials, equipment, facilities and supervision to provide for the collection, security, temporary storage and transportation or shipment of the samples to a laboratory.
“Commercial motor vehicle” means a motor vehicle or combination of motor vehicles used in commerce to transport passengers or property if the motor vehicle:
Has a gross combination weight rating of 26,001 or more pounds; or
Has a gross vehicle weight rating of 26,001 or more pounds; or
Is designed to transport 16 or more passengers, including the driver; or
Is of any size and is used in the transportation of materials found to be hazardous for the purposes of the Hazardous Materials Transportation Act and which require the motor vehicle to be placarded under the Hazardous Materials Regulations (49 CFR, Part 172, 1308).
“Driver” means any person who operates a commercial motor vehicle. This includes, but is not limited to: Full time, regularly employed drivers; casual, intermittent or occasional drivers; leased drivers and independent, owner-operator contractors who are either directly employed by or under lease to an employer or who operate a commercial motor vehicle at the direction of or with the consent of an employer. For the purpose of pre-employment/pre-duty testing only, the term “driver” includes a person applying to an employer to drive a commercial motor vehicle.
“Drug” means any substance (other than alcohol) that is a controlled substance as defined in the section and 49 CFR, Part 40.
“FMCSA” means the Federal Motor Carrier Safety Administration; US Department of Transportation.
“Owner-operator(s)” means a driver(s) who has been contracted for services with . For the purposes of these procedures and 's Alcohol and Drug Abuse Policy, owner-operators are not to be considered employees, but will be required to participate in 's Alcohol and Drug Abuse Policy like all Company employee drivers.
“Medical review officer” (MRO) means a licensed MD or DO with knowledge of drug abuse disorders that is employed or used by a motor carrier to conduct drug testing in accordance with this part.
“Performing a safety-sensitive function” means a driver is considered to be performing a safety-sensitive function during any period in which he/she is actually performing, ready to perform, or immediately available to perform any safety-sensitive functions.
“Random selection process” means that alcohol and drug tests are unannounced; that every driver of a motor carrier subject to test/tests conducted annually shall equal or exceed ten percent (10%) for alcohol tests and fifty percent (50%) for drug test of the total number of drivers subject to testing of a motor carrier.
“Reasonable cause” means that the motor carrier believes the actions or appearance or conduct of a commercial motor vehicle driver who is on duty as defined below, are indicative of the use of a controlled substance.
"Refusal" is defined below:
(a) As an employee, you have refused to take a drug test if you:
(1) Fail to appear for any test (except a pre-employment test) within a reasonable time, as determined by the employer, consistent with applicable DOT agency regulations, after being directed to do so by the employer. This includes the failure of an employee (including an owner-operator) to appear for a test when called by a C/TPA (see §40.61(a));
(2) Fail to remain at the testing site until the testing process is complete; Provided, That an employee who leaves the testing site before the testing process commences (see §40.63 (c)) for a pre-employment test is not deemed to have refused to test;
(3) Fail to provide a urine specimen for any drug test required by this part or DOT agency regulations; Provided, That an employee who does not provide a urine specimen because he or she has left the testing site before the testing process commences (see §40.63 (c)) for a pre-employment test is not deemed to have refused to test;
(4) In the case of a directly observed or monitored collection in a drug test, fail to permit the observation or monitoring of your provision of a specimen (see §§40.67(l) and 40.69(g));
(5) Fail to provide a sufficient amount of urine when directed, and it has been determined, through a required medical evaluation, that there was no adequate medical explanation for the failure (see §40.193(d)(2));
(6) Fail or decline to take an additional drug test the employer or collector has directed you to take (see, for instance, §40.197(b));
(7) Fail to undergo a medical examination or evaluation, as directed by the MRO as part of the verification process, or as directed by the DER under §40.193(d). In the case of a pre-employment drug test, the employee is deemed to have refused to test on this basis only if the pre-employment test is conducted following a contingent offer of employment. If there was no contingent offer of employment, the MRO will cancel the test; or
(8) Fail to cooperate with any part of the testing process (e.g., refuse to empty pockets when directed by the collector, behave in a confrontational way that disrupts the collection process, fail to wash hands after being directed to do so by the collector).
(9) For an observed collection, fail to follow the observer’s instructions to raise your clothing above the waist, lower clothing and underpants, and to turn around to permit the observer to determine if you have any type of prosthetic or other device that could be used to interfere with the collection process.
(10) Possess or wear a prosthetic or other device that could be used to interfere with the collection process.
(11) Admit to the collector or MRO that you adulterated or substituted the specimen.
“Safety-sensitive function” means any of those on-duty functions set forth in CFR 49, Section 395.2.
“On duty time” means all time from the time a driver begins to work or is required to be in readiness to work until the time he/she is relieved from work and all responsibility for performing work. “On duty time” shall include:
All time at a carrier or shipper plant, terminal, or facility, or other property, or on any public property waiting to be dispatched, unless the driver has been relieved from duty by the motor carrier;
All time inspecting, servicing, or conditioning any commercial motor vehicle at any time;
All driving time;
All time, other than driving time, in or upon any commercial motor vehicle except time spent resting in a sleeper berth;
All time loading or unloading a vehicle, supervising, or assisting in the loading or unloading, attending a vehicle being loaded or unloaded, remaining in readiness to operate the vehicle, or in giving or receiving receipts for shipments loaded or unloaded.
All time repairing, obtaining assistance, or remaining in attendance upon a disabled vehicle.
III. SUBSTANCES PROHIBITED/PRESCRIPTION MEDICATIONS
A. Alcohol use means the consumption of any beverage, mixture, or preparation, including any medication containing alcohol which, when consumed, causes an alcohol concentration in excess of those prescribed by Part 382, Subpart B, (FMCSR) and Section IV of this policy.
B. Controlled substances: In accordance with FMCSA rules, urinalysis will be conducted to detect the presence of the following substances:
Detection levels requiring a determination of a positive result shall be in accordance with the guidelines adopted by the FMCSA in accordance with the recommendations established by the 49 CFR, Part 40.
C. Prescription medications: Drivers taking legally prescribed medications issued by a licensed health care professional familiar with the driver's work-related responsibilities must report such use to their immediate supervisor or dispatcher, and may be required to present written evidence from the health care professional which describes the effects such medications may have on the driver's ability to perform his/her tasks.
In the sole discretion of the alcohol and drug program administrator, a driver may be temporarily removed from a safety-sensitive position if deemed appropriate.
A. Alcohol Prohibitions:
The new alcohol rule prohibits any alcohol misuse that could affect performance of a safety-sensitive function, including:
Use while performing safety-sensitive functions.
Use during the 4 hours before performing safety-sensitive functions.
Reporting for duty or remaining on duty to perform safety-sensitive functions with an alcohol concentration of 0.04 or greater.
Possession of alcohol, unless the alcohol is manifested and transported as part of a shipment. This includes the possession of medicines containing alcohol (prescription or over-the-counter), unless the packaging seal is unbroken.
Use during 8 hours following an accident, or until he/she undergoes a post accident test.
Refusal to take a required test.
NOTE: A driver found to have an alcohol concentration of 0.02 or greater but less than 0.04 shall not perform, nor be permitted to perform, safety-sensitive functions for at least 24 hours. The other consequences imposed by the regulations and discussed below do not apply. However, documentation of this test constitutes written warning that company policy has been violated, and the next occurrence could result in disqualification of a driver.
B. Drug Prohibitions:
The regulations prohibit any drug use that could affect performance of safety-sensitive functions, including:
Use of any drug, except by doctor's prescription, and the only if the doctor has advised the driver that the drug will not adversely affect the driver's ability to safely operate the CMV;
Testing positive for drugs; and
Refusing to take a required test.
All drivers will inform the alcohol and drug program administrator of any therapeutic drug use prior to performing a safety-sensitive function.
V. DRIVER APPLICANT AND CURRENT DRIVER TESTING
A. Applicant Testing: All driver applicants will be required to submit to and pass a urine drug test as a condition of employment. All driver applicants may be required to submit to and pass a Breath Alcohol Screen prior to employment. Job applicants who are denied employment because of a positive test may reapply for employment after 6 months.
Offers of employment are made contingent upon passing the Company's medical review, including the alcohol and drug test. Driver applicants who have received firm employment offers are to be cautioned against giving notice at their current place of employment, or incurring any costs associated with accepting employment with the Company until after medical clearance has been received. Under no circumstances may a driver perform a safety-sensitive function until a confirmed negative result is received.
Driver applicant drug testing shall follow the collection, chain-of-custody and reporting procedures as set forth in 49 CFR, Part 40.
B. Employee Drivers: Under all circumstances, when a driver is directed to provide either a breath test or urine sample (Appendix C) in accordance with these procedures, he/she must immediately comply as instructed. Refusal will constitute a positive result, and the driver will be immediately removed from the safety-sensitive function, and will be subject to further discipline or termination as appropriate.
a. Reasonable Suspicion: If a driver is having work performance problems or displaying behavior that may be alcohol or drug-related, or is otherwise demonstrating conduct that may be in violation of the Policy where immediate management action is necessary, a supervisor or dispatcher, with the concurrence of the alcohol and drug program administrator, will require driver to submit to a breath test or urinalysis. The following conditions are signs of possible alcohol or drug use (not all-inclusive):
Abnormally dilated or constricted pupils
Glazed stare – redness of eyes
Change of speech (i.e. faster or slower)
Redness under nose
Sudden weight loss
Change in personality (i.e. paranoia)
Increased appetite for sweets
Forgetfulness – performance faltering – poor concentration
Borrowing money from coworkers or seeking an advance of pay or other unusual display of need for money
Constant fatigue or hyperactivity
Smell of alcohol
Excessive, unexplained absences
Dulled mental processes
Slowed reaction rate
b. Supervisors or Dispatchers must take action if they have reason to believe one or more of the above-listed conditions is indicated, and that the substance abuse is affecting a driver's job performance or behavior in any manner. A supervisor or dispatcher observing such conditions will take the following actions immediately:
Confront the employee involved, and keep under direct observation until the situation is resolved.
Secure the alcohol and drug program administrator's concurrence to observations; job performance and company policy violations must be specific.
After discussing the circumstances with the supervisor or dispatcher, the alcohol and drug program administrator will arrange to observe or talk with the driver. If he/she believes, after observing or talking to the driver, that the conduct or performance problem could be due to substance abuse, the driver will be immediately informed that continued refusal will result in disqualification from performing any safety-sensitive function.
Employees will be asked to release any evidence relating to the observation for further testing. Failure to comply may subject the employee to subsequent discipline or suspension from driving duties. All confiscated evidence will be receipted with signatures of both the receiving supervisor, as well as the provider.
If upon confrontation by the supervisor or dispatcher, the driver admits to use but requests assistance, the alcohol and drug program administrator will arrange for assessment by an appropriate substance abuse professional (SAP). Reassignment to the driver position is conditional to completing the SAP's guidelines and return-to-work testing.
c. The supervisor or dispatcher shall, within 24 hours or before the results of the controlled substance test are released, document the particular facts related to the behavior or performance problems, and present such documentation to the alcohol and drug program administrator.
d. The drug and alcohol program administrator will remove or cause the removal of the driver from the Company-owned vehicle and ensure that the driver is transported to an appropriate collection site an thereafter to the driver's residence or, where appropriate, to a place of lodging. Under no circumstances will that driver be allowed to continue to drive a Company vehicle or his/her own vehicle until a confirmed negative test result is received.
e. If, during the course of employment, the driver acknowledges a substance abuse problem and requests assistance, the problem may be treated as if it were an illness, subject to the provisions set forth below:
The decision to seek diagnosis and accept treatment for the substance abuse problem is the responsibility of the driver;
The diagnosis and prescribed treatment of the driver's condition will be determined by health care professionals designated by the alcohol and drug program administrator in conjunction with the driver's physician; and
The driver might be placed on medical leave for a predetermined period recommended by those medical professionals if the SAP determines that such action is appropriate.
2. Post-Accident Testing: Currently, federal regulations place the burden of compliance with post-accident alcohol and drug testing regulations on the driver. Therefore, all drivers are required to provide a breath test and a urine specimen to be tested for the use of controlled substances “as soon as practicable” after an accident. The driver shall remain readily available for such testing or may be deemed by the alcohol and drug program administrator to have refused to submit to testing. No alcohol may be consumed for 8 hours after the accident or until a test is conducted. If the driver is seriously injured and cannot provide a specimen at the time of the accident, he/she shall provide the necessary authorization for obtaining hospital reports and other documents that would indicate whether there were any controlled substances in his/her system.
An accident is defined by FMCSA regulations as an accident which results in the death of a human being or bodily injury to a person who, as a result of the injury, immediately receives medical treatment away from the scene of the accident; or which has had one of the vehicles towed from the scene of the accident. Except for a fatality accident, verification of the driver's responsibility in the above accident must be established by a citation to the driver.
Adherence by drivers to post-accident specimen collection requirements is a condition of continued employment. The failure of a driver to comply with DOT post-accident and specimen collection rules will be considered a breach of his/her contract with the Company, and the contract is invalid until appropriate substance abuse professional counseling has been completed.
3. Random Testing: The Company will conduct random testing for all covered drivers as follows:
A company-wide selection process which removes discretion in selection from any supervisory personnel will be adopted by the Company. This process will select covered drivers through the use of a computerized program.
The random testing, once begun, will provide for alcohol testing of at least and for drug testing of at least of all covered drivers.
The random testing will be reasonably spaced over any 12 month period.
Once notified, a driver must proceed immediately to the assigned collection site.
The company reserves the right to request a driver to submit to a drug test even while off duty.
4. The alcohol and drug program administrator will be responsible for designating the appropriate substance abuse professional who, in conjunction with the driver's physician, will diagnose the problem and recommend treatment.
The driver's successful completion of the approved treatment program is a condition of continued employment as a driver.
Following successful completion of any approved treatment program, the driver will be required to submit to at least six random drug tests during the first year, and follow-up testing may be conducted for up to 60 months. Failure to adhere to this condition is grounds for immediate termination.
All supervisors or dispatchers will receive training to assist them in identifying alcohol and drug behavioral characteristics.
5. Return-to-Duty Testing: Before a driver returns to duty requiring the performance of a safety-sensitive function after engaging in conduct prohibited by this policy and Part 382, Subpart B (FMCSR), the driver shall undergo a return to duty alcohol test with a result of less than a 0.02 BAC or receive a confirmed negative result from a controlled substance urinalysis test.
VI. COLLECTION OF BREATH AND URINE SPECIMENS AND LABORATORY ANALYSIS
Breath alcohol testing will be conducted either on site or at a prearranged location by a qualified Breath Alcohol Technician according to 49 CFR, Part 40 procedures. Refusal to complete and sign the testing form or refusal to provide breath will be considered a positive test, and the driver will be removed from a safety-sensitive function until resolved.
Specimen Collection: Specimen collection will be conducted in accordance with applicable state and federal law. The collection procedures will be designed to ensure the security and integrity of the specimen provided by each driver, and those procedures will strictly follow federal chain-of-custody guidelines. Moreover, every reasonable effort will be made to maintain the dignity of each driver submitting a specimen for analysis in accordance with these procedures.
Laboratory Analysis: As required by FMCSA regulations, only a laboratory certified by Department of Health and Human Services (DHHS) to perform urinalysis for the detection of the presence of controlled substances will be retained by the Company. The laboratory will be required to maintain strict compliance with federally approved chain-of-custody procedures, quality control, maintenance and scientific analytical methodologies.
VII. CONSEQUENCES: APPEAL OF TEST RESULTS
Alcohol and drug abuse may not only threaten the safety and productivity of all employees at , but causes serious individual health consequences to those who use them. Appendix A outlines several personal consequences which may result after abuse of controlled substances. Any confirmed actions prohibited by Part IV above, while performing a safety-sensitive function or refusing to take a breath test, will be grounds for disqualification as a driver.
A driver testing positive for alcohol or drug use is subject to disqualification. Refusal to submit to testing will also be considered a positive.
Refusal may be defined as not providing a breath sample or urine as directed, neglecting to sign appropriate control forms, using alcohol within 8 hours of an accident, or engaging in conduct that clearly obstructs the testing process.
Any driver testing positive for the presence of a controlled substance will be contacted by the Company's MRO. The driver will be allowed to explain and present medical documentation to explain any permissible use of a drug. All such discussions between the driver and the MRO will be confidential. The Company will not be a party to, or have access to, matters discussed between the driver and the MRO. If medically supportable reasons exist to explain the positive result, the MRO will report the test result to the Company as a negative.
Within 72 hours after the driver has been notified of a positive test result for drugs, he/she may request a retest of the split sample. This signed request will be provided to the MRO in writing, who will then initiate the new laboratory analysis. If a different result is detected by the subsequent laboratory, the test will be voided by the MRO, and the company alcohol and drug program administrator will be notified. A retest may be initiated as appropriate.
Under no circumstances, unless required or authorized by law, will alcohol or drug testing information or results for any employee or applicant be released without written request from the applicable employee.
Drivers are entitled, upon written request within 30 days, to obtain copies of any records pertaining to the driver's use of alcohol or controlled substances, including any records pertaining to his or her alcohol or controlled substance test.
Collection of breath and urine samples must always be documented and sealed with a tamper-proof sealing system in the presence of the driver, to ensure that all tests can be correctly traced to the driver.
Drug test analysis from the DHHS approved laboratory will be forwarded directly to the Medical Review Officer assigned by the alcohol and drug program administrator.
Alcohol test results will be forwarded by the MRO to the alcohol and Drug program administrator for confidential recordkeeping.
ALCOHOL AND DRUG EFFECTS
Section 382.601(b)(11) FMCSR mandates that all employees be provided with training material discussing the effects of alcohol and controlled substance use on an individual's health, work, and personal life.
This attachment is intended to help individuals understand the personal consequences of substance abuse.
Although used routinely as beverage for enjoyment, alcohol can also have negative physical and mood-altering effects when abused. These physical or mental alterations in a driver may have serious personal and public safety risks.
An average of three or more servings per day of beer (12 ounces), whiskey (1 ounce), or wine (6 ounces) over time, may result in the following health hazards:
Fatal liver diseases
Decreased sexual function
Increased cancers of the mouth, pharynx, esophagus, rectum, breast, and malignant melanoma
Spontaneous abortion and neonatal mortality
Social Issues/Workplace Issues
2 of 3 homicides are committed by people who drink prior to the crime.
2 – 3% of the driving population are legally drunk at any one time. This rate doubles at night and on weekends.
2 of 3 Americans will be involved in an alcohol-related vehicle accident during their lifetime.
The separation and divorce rate in families with alcohol dependency problems is 7 times the average.
40% of family court cases are alcohol-related.
Alcoholics are 15 times more likely to commit suicide.
More than 60% of burns, 40% of falls, 69% of boating accidents, and 76% of private aircraft accidents are alcohol-related.
Over 17,000 fatalities occurred in 1993 in highway accidents, which were alcohol-related. This was 43% of all highway fatalities.
30,000 people will die each year from alcohol-caused liver disease.
10,000 people will die each year due to alcohol-related brain disease or suicide.
Up to 125,000 people die each year due to alcohol-related conditions or accidents.
It takes one hour for the average person (150 pounds) to process one serving of alcohol from the body.
Impairment can be measured with as little as two drinks in the body.
A person who is legally intoxicated is 6 times more likely to have an accident that a sober person.
ALCOHOL'S TRIP THROUGH THE BODY
Mouth and Esophagus: Alcohol is an irritant to the delicate linings of the throat and food pipe. It burns as it goes down.
Stomach and Intestines: Alcohol has an irritating effect on the stomachs’ protective lining, resulting in gastric or duodenal ulcers. This condition, if it becomes acute, can cause peritonitis, or perforation of the stomach wall. In the small intestine, alcohol blocks absorption of such substances as thiamine, folic acid, fat, vitamin B1, vitamin B12, and amino acids.
Bloodstream: 95% of the alcohol taken into the body is absorbed into the bloodstream through the lining of the stomach and duodenum. Once in the bloodstream, alcohol quickly goes to every cell and tissue in the body. Alcohol causes red blood cells to clump together in sticky wads, slowing circulation and depriving tissues of oxygen. It also causes anemia by reduction red blood cell production. Alcohol slows the ability of white cells to engulf and destroy bacteria and degenerates the clotting ability of blood platelets.
Pancreas: Alcohol irritates the cells of the pancreas, causing them to swell, thus blocking the flow of digestive enzymes. The chemicals, unable to enter the small intestine, begin to digest the pancreas, leading to acute hemorrhagic pancreatitis. One out of five patients who develop this disease dies during the first attack. Pancreatitis can destroy the pancreas and cause a lack of insulin, thus resulting in diabetes.
Liver: Alcohol inflames the cells of the liver, causing them to swell and block the tiny canal to the small intestines. This prevents bile from being filtered properly through the liver. Jaundice develops, turning the whites of the eyes and skin yellow. Each drink of alcohol increases the number of live cells destroyed, eventually causing cirrhosis of the liver. This disease is eight times more frequent among alcoholics than among non-alcoholics.
Heart: Alcohol causes inflammation of the heart muscle. It has a toxic effect on the heart and causes increased amounts of fat to collect, thus disrupting its normal metabolism.
Urinary Bladder and Kidneys: Alcohol inflames the lining of the urinary bladder making it unable to stretch properly. In the kidneys, alcohol causes increased loss of fluids through its irritating effect.
Sex Gland: Swelling of the prostate gland caused by alcohol interferes with the ability of the male to perform sexually. It also interferes with the ability to climax during intercourse.
Brain: The most dramatic and noticed effect of alcohol is on the brain. It depresses brain centers, producing progressive un-coordination: confusion, disorientation, stupor, anesthesia, coma, death. Alcohol kills brain cells and brain damage is permanent Drinking over a period of time causes loss of memory, judgment and learning ability.
Health Effects/Workplace Issues
One joint of marijuana contains cancer-causing substances equal to 1/2 pack of cigarettes.
One joint causes the heart to race and be overworked. People with heart conditions are at
Marijuana is commonly contaminated with the fungus Aspergillus which can cause serious respiratory tract and sinus infections.
Marijuana lowers the body's immune system response, making users more susceptible to
Chronic smoking causes changes in brain cells and brain waves. The brain does not work as efficiently or effectively. Long-term brain damage may occur.
Tetrahydrocannabinot (THC) and 60 other chemicals in marijuana concentrate in the ovaries and testes.
Chronic smoking of marijuana in males causes a decrease in testosterone and an increase in estrogen, the female hormone. As a result, the sperm count is reduced, leading to temporary sterility.
Chronic smoking of marijuana in females causes a decrease in fertility.
A higher than normal incidence of stillborn babies, early termination of pregnancy, and higher infant mortality ate during the first few days of life is common in pregnant marijuana smokers.
THC causes birth defects including brain damage, spinal cord, forelimbs, liver and water on the brain and spine in test animals.
Prenatal exposure may cause underweight newborn babies.
Fetal exposure may decrease visual functioning.
User's mental function can display the following effects:
delayed decision making
impaired short-term memory
impaired signal detection
erratic cognitive function
distortion of time estimation
THC is stored in body fat and slowly released.
Marijuana smoking has long-term effects on performance.
Increased THC potency in modern marijuana dramatically compounds the side effects.
Combining alcohol or other depressant drugs with marijuana increases the impairing effects of both.
Used medically as a local anesthetic. When abused, it becomes a powerful physical and mental stimulant. The entire nervous system is energized. Muscles tense, heart beats faster and stronger, and the body burns more energy. The brain experiences an exhilaration caused by a large release of neurohormones associated with mood elevation.
Regular use may upset the chemical balance of the brain. As a result, it may speed up the aging process causing damage to critical nerve cells. Parkinson's disease could also occur.
Cocaine causes the heart to beat faster, harder, and rapidly increases blood pressure. It also causes spasms of blood vessels in the brain and heart. Both lead to ruptured vessels causing strokes and heart attacks.
Strong dependence can occur with one “hit” or cocaine. Usually mental dependency occurs within days for “crack” or within several months for snorting coke. Cocaine causes the strongest mental dependency of all the drugs.
Treatment success rates are lower than with any other chemical dependency.
Extremely dangerous when taken with other depressant drugs.
Death due to overdose is Likely.
Effects are usually not reversible by medical intervention.
Extreme mood and energy swings create instability. Sudden noise causes a violent reaction.
Lapses in attention and ignoring warning signals increases probability of accidents.
High cost frequently leads to theft and/or dealing.
Paranoia and withdrawal may create unpredictable or violent behavior.
Performance is characterized by forgetfulness, absenteeism, tardiness, and missing appointments.
Narcotic drugs which alleviate pain and depress body functions and reactions.
IV needle users have a high risk of contracting hepatitis or H.I.V. when sharing needle.
Increased pain tolerance. As a result, a person may more severely injure themselves and fail to seek medical attention as needed.
Narcotic effects are multiplied when combined with other depressants causing an increased risk for overdose.
Because of tolerance, there is an ever increasing need for more.
Strong mental and physical dependency occurs.
With increased tolerance and dependency combined, there is a serious financial burden for the users.
Is a Central nervous system stimulant that speeds up the mind and body.
Regular use causes strong psychological dependency and increased tolerance.
High doses may cause toxic psychosis resembling schizophrenia.
Intoxication may induce a heart attach or stroke due to increased blood pressure.
Chronic use may cause heart or brain damage due to severe constriction of capillary blood vessels.
Euphoric stimulation increases impulsive and risk taking behavior, including bizarre and violent behavior.
Withdrawal may result in severe physical and mental depression.
Since the drug alleviates the sensation of fatigue, it may be abused to increase alertness during periods of overtime or failure to get rest.
With heavy use or increasing fatigue, the short-term mental or physical enhancement reverses and becomes impairment.
Often used as a large animal tranquilizer. Abused primarily for its mood altering effects. Low doses produce sedation and euphoric mood changes. Mood can rapidly change from sedation to excitation and a blank stare. Sudden noises or physical shocks may cause a “freak out” in which the person has abnormal strength, violent behavior, and an inability to speak or comprehend.
The potential for accidents and overdose emergencies is high due to the extreme mental effects combined with the anesthetic effect on the body.
PCP, when combined with other depressants, including alcohol, increases the possibility of an
If misdiagnosed as LSD induced, and treated with Thorazine, can be fatal.
Irreversible memory loss, personality changes, and thought disorders may result.
Not common in workplace primarily because of the severe disorientation that occurs.
There are four phases to PCP abuse:
Acute toxicity causing combativeness, catatonia, convulsions, and coma. Distortions of size, shape, and distorted perception are common.
Toxic psychosis with visual and auditory delusions, paranoia and agitation.
Drug induced schizophrenia.
Induced depression which may create suicidal tendencies and mental dysfunction.
This document has been assembled electronically for review and Signature, the above named person will review and digitally sign this document only when they are satisfied with the policies and procedures listed.
is pleased to offer you a position with the company. We have several policies that we take seriously. We would like to have you read and sign the following document. If you have any questions, please ask your supervisor for clarification. We look forward to having you as a member of the team and hope that you have a great experience.
Equal Employment Opportunity (“EEO”) Policy
is an equal opportunity employer and complies fully with all government laws and regulations concerning nondiscriminatory employment practices. We believe that all persons are entitled to equal employment opportunities.
In order to provide equal employment and advancement opportunities to all individuals, employment decisions at will be based on merit, qualifications and abilities. does not discriminate against employees or applicants for employment on the basis of race: color: creed: religion: sex: national origin: age: the presence of any sensory, mental or physical disability: sexual orientation, gender identity or gender expression: marital status: honorably discharged veteran and military status: political affiliation or ideology: or any other characteristic or status protected by applicable federal, state or local law. This policy governs all aspects of employment, including, but not limited to, recruiting, hiring, selection, training, job assignment, compensation, benefits, promotions, transfers, discipline, layoffs and termination.
Anti-Discrimination and Anti-Harassment Policy
Harassment and discrimination are forms of employee misconduct that undermine the integrity of the employment relationship. They may also violate the law. It is the policy of to maintain a work environment free from all forms of prohibited harassment and discrimination, including but not limited to, harassment or discrimination on the basis of race: color: creed: religion: sex: national origin: age: the presence of any sensory, mental or physical disability: sexual orientation, gender identity or gender expression: marital status: honorably discharged veteran and military status: political affiliation or ideology: or any other characteristic or status protected by applicable federal, state or local law. This policy includes, but is not limited to, harassing or discriminatory conduct of a sexual nature.
Prohibited harassment may consist of the following types of behavior, although it is not limited to these examples:
Jokes, comments, slurs, innuendo, pranks, or remarks that are "off color" or derogatory to a person based on his or her race, color, creed, religion, sex, national origin, age, the presence of any sensory, mental or physical disability, sexual orientation and gender identity and expression, marital status, honorably discharged veteran and military status, political affiliation or ideology, or any other characteristic or status protected by applicable federal, state or local
Pictures, cartoons, articles, or centerfolds that are sexist, racist, or derogatory as listed above.
Unwanted, inappropriate, or offensive looks, touches, gestures or other physical conduct.
Explicit or implicit pressure for a sexual or romantic relationship as a condition of employment or as a condition for any employment decision or benefit.
Sexual harassment is defined as follows: unwelcome sexual advances, requests for sexual favors, and other verbal or physical conduct of a sexual nature constitute sexual harassment when:
Submission to such conduct is made either explicitly or implicitly a term or condition of the individual's employment;
Submission to or rejection of such conduct by an individual is used as a basis for employment decisions such individual; or
Such conduct has the purpose or effect of unreasonably interfering with an individual’s work performance or creating an intimidating, hostile or offensive environment.
I acknowledge that I have been provided a copy of, have read and understand the EEO, Anti- Discrimination and Anti-Harassment policy. I further agree to adhere to this policy.
I have read and agree
Complaint Procedure, Investigation, and Corrective Action
Conduct by employees in violation of ’s EEO or Anti-Discrimination and Anti-Harassment Policies is absolutely prohibited and will not be tolerated.
If you believe that you have been or may be subjected to any harassment or discrimination in violation of ’s policies, including but not limited to, sexual harassment or discrimination, you must promptly report any such incident to the Human Resources Manager. You should include details of the incident or incidents, the names of the individuals involved, and the names of any witnesses.
Every reported incident of harassment or discrimination will be promptly and appropriately investigated. While confidentiality cannot be guaranteed, investigations will be handled as discretely and confidentially as practicable under the circumstances, consistent with’s need to conduct an adequate investigation.
Any employee found, after a reasonable investigation, to have engaged in conduct in violation of ’s EEO Anti-Discrimination and Anti-Harassment Policies, will be subject to prompt and appropriate corrective action. Appropriate action might range from counseling to termination of employment. The complaining individual will be advised when the investigation has been completed. However, specific details regarding any corrective action are usually confidential and are not provided to the complaining individual.
No Retaliation Policy
Retaliation against an individual for exercising his or her rights under 's EEO Anti-Discrimination and Anti-Harassment Policies is strictly prohibited and is a separate violation of these policies. This includes any retaliation for inquiring about rights under these Policies or reporting or complaining in good faith about possible violations or assisting in a complaint investigation, including providing information he or she in good faith believes to be about a possible violation. Concerns regarding retaliation should be reported and will be investigated using the same process under 's Complaint Procedure set forth above.
Drug and Alcohol Policy
I certify that I have been provided a copy of and have read the policy on Alcohol and Drug Testing procedures. I understand that as a condition of employment as a driver/employee, I must comply with these guidelines, and do agree that I will remain medically qualified by following these procedures. If I develop a problem with drug alcohol or drug abuse during my employment with , I will seek assistance through the current alcohol and drug testing program administrator.
Employee Nondisclosure Agreement
In consideration of my employment with and my receipt of the compensation now and hereafter paid to me by and as a condition of my employment by , I agree to the following:
Company Information: I agree at all times during the term of my employment and thereafter, to hold in strictest confidence, and not to use except for the benefit of , or to disclose to any person, firm or corporation without written authorization from the CEO or President any confidential information of , except to the extent required to perform Employee’s duties and responsibilities or as may be compelled in connection with any legal proceeding. I understand that “Confidential Information” means any proprietary information, trade secrets or know-how, including but not limited to: research, product plans, products, services, Employee manuals, memos, customer lists and customers (including but not limited to: customers of on whom I called or with whom I became acquainted with during the term of my employment), markets, software, processes, formulas, marketing, finances and other business information disclosed to me by either directly or indirectly in writing, orally or by drawings or observation of parts or equipment. I further understand that Confidential Information does not include any of the foregoing items which have become publicly known or made available through no wrongful act of mine or of others who were under confidentiality obligations as to the item or items involved.
Former Employer information: I agree that I will not, during my employment with , improperly use or disclose and proprietary information or trade secrets of any former or current employer or other person or entity and that I will not bring onto the premises of any unpublished documents or proprietary information belonging to any such employer, person or entity unless consented to in writing by such employer, person or entity.
Third Party Information: I recognize that has received and in the future will receive from third parties their confidential or proprietary information subject to a duty on 's part to maintain the confidentiality of such information and to use it only for certain limited purposes. I agree to hold all such confidential or proprietary information in the strictest confidence and not to disclose it to any person, firm, or corporation or to use it except as necessary in carrying out my work for consistent with the Company's agreement with such third party.
Confidential Information Remains Property of . All Confidential Information, whether tangible or intangible, shall be the sole and exclusive property of . I agree to hold in trust solely for the benefit of all such Confidential Information offered, made, conceived, or developed or made available (or any copies or extracts thereof). I will use such materials only as required during the term of my employment or as authorizes in writing.
Rights to Creations
I agree to promptly disclose and assign to all Creations (as defined hereunder) that I create (either alone or with others) during my employment with , if the Creations: (i) relate, at the time created, to ’s business; or (ii) result from any work performed for ; or (iii) were created, in whole or part, through the use of any of ’s Confidential Information, time or property, including without limitation equipment, materials, documents, resources, supplies, and or facilities. I agree that all Creations are hereby assigned to and are ’s exclusive property. shall have the exclusive worldwide rights, in all languages and in perpetuity, to use, license, exploit, sell, assign or otherwise dispose of all or any of the Creations, in any format or version, by any means and in any media, now known or hereafter developed. I hereby waive any and all claims that I may now or hereafter have in any jurisdiction to so-called moral rights to the Creations. I agree to execute, acknowledge and deliver to such applications, assignments, and other documentation necessary for to apply for, register, and obtain any trademark, patent or copyright or otherwise protect the Creations. I agree to assist in any proceeding, litigation or arbitrations relating to and protecting ’s rights in the Creations.
As used herein, “Creations” shall refer to any means of compositions, discoveries, improvements, inventions (whether or not protectable under patent laws), works of authorship including without limitation to computer programming or coding, mobile applications, software, information fixed in any tangible medium of expression (whether or not protectable under copyright laws), moral rights, mask works, trademarks, trade names, trade dress, trade secrets, know-how, concepts, ideas (whether or not protectable under trade secret laws) and all other subject matter protectable under patent, copyright, moral right, mask work, trademark, trade secret or other laws, and includes without limitation all new or useful art, combinations, research, software, programs, techniques, technical developments, and tests.
Returning Company Documents
I agree that, at the time of leaving the employment of , I will deliver to (and will not keep in my possession, recreate or deliver to anyone else) any and all devices, records, data, notes, reports, proposals, lists correspondence, materials, equipment, other documents or property, keys, radios or reproductions of any aforementioned items associated with my employment with or otherwise belonging to .
Service Gratuity & Safety Bonus Plan
I acknowledge that I understand it is acceptable to receive a gratuity from a customer, passenger or other person or entity, however it is not acceptable to solicit gratuities from any customer, passenger or other person or entity in any way at any time.
I have read and agree
I agree to execute any proper oath or verify any proper document required to carry out the terms of this agreement. I represent that my performance of all the terms of this agreement will not breach any agreement to keep in confidence proprietary information acquired by me in confidence or in trust prior to my employment with . I have not entered into, and I agree I will not enter into, any oral or written agreement in conflict herewith.
I agree it would be impossible or inadequate to measure and calculate 's damages from any breach of the covenants set forth in this agreement. Accordingly, I agree that if I breach any of these covenants, will have available, in addition to any other right or remedy available, the right to obtain an injunction from a competent jurisdiction restraining such breach or threatened breach and to specific performance of any such provision of this agreement. I further agree that no bond or other security shall be required in obtaining such equitable relief and I hereby consent to the issuance of such injunction and to the ordering of specific performance.
At Will Employment: Many States are an “at-will” employment state. As such, if applicable, either party may terminate your employment with at any time for any reason whatsoever, with or without cause or advance notice.
Severability: If one or more of the provisions in this agreement are deemed void by law, then the remaining provisions will continue in full force and affect.
Successors and Assigns: This agreement will be binding upon my heirs, executors, administrators, and other legal representatives and will be for the benefit of , its successors, and its assigns.
Acknowledged and Agreed
Leave this empty:
Your legal name
Your email address
If you have questions about the contents of this document, you can email the document owner.
Document Name: Employment Application
Agree & Sign