5 If a driver is selected at random, for either drug or alcohol testing, a Company official will notify the driver. Once notified, every action the driver takes must lead to a collection.
CDL Driver Application for Employment 316 W Milwaukee St., New Hampton, IA 50659 800-222-6047 | ZIPS.COM Name____________________________________________________________________________________________ (First) (Middle) (Maiden name, if any) (Last) Address ______________________________________________________________________How Long?__________ (Street) (City) (State & Zip Code) Date of Birth _____________________Social Security No.__________________________Hire Date________________ Telephone number ________________________E-mail address_____________________________________________ Previous Three Years Residency. Attach sheet if more space is needed. ___________________________________________________________________________________# years________ (Street) (City) (State & Zip Code) ___________________________________________________________________________________# years________ (Street) (City) (State & Zip Code) ___________________________________________________________________________________# years________ (Street) (City) (State & Zip Code) License information 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 that I do not have more than one motor vehicle license, the information for which is listed below. State License Type Expiration Date Driving experience Class of Equipment Straight Truck Tractor & Semi-Trailer Tractor & Two Trailers Other Type of Equipment (Van, Tank, Flat, Etc.) Dates From To Approximate No. of Miles (Total) Accident record for past 3 years or more. Attach sheet if more space is needed. Dates Nature of Accident (Head-on, Rear-End, Upset, Etc. No. Fatalities No. Injured Chemical Spill Yes No Yes No Yes No Traffic convictions and forfeitures for the past 3 years (other than parking violations). Attach sheet if more space is needed. Date Convicted (Month/Year) Violation State of Violation Location Penalty (Forfeited bond, collateral and/or points) A. Have you ever been denied a license, permit or privilege to operate a motor vehlcle? Yes________No_______ If yes, explain________________________________________________________________________________ B. Has any llcense, pemiit or privilege ever been suspended or revoked? Yes________No_______ If yes, explain ________________________________________________________________________________ 1 Employment Record. Attach sheet if more space is needed. Applicants who 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 for a total of 10 years employment record. Must list the complete mailing address: street number and name, city, state and zip code. Last employer:________________________________________________________________________________________________ Address____________________________________________________________________Phone____________________________ Position held________________________________________________From____________To____________Salary______________ Reasons for leaving____________________________________________________________________________________________ Any gaps in employment and/or unemployment must be explained. Include dates (month/year) and reason. ___________________________________________________________________________________________________________ Were you subject to the federal motor carrier safety regulations (FMCSR) while employed by the previous employer? Yes no Was the previous job position designated as a safety-sensitive function in any DOT regulated mode, subject lo alcohol and controlled substances testing requirements as required by 49 CFR, Part 40? Yes no Second Last employer:_________________________________________________________________________________________ Address____________________________________________________________________Phone____________________________ Position held________________________________________________From____________To____________Salary______________ Reasons for leaving___________________________________________________________________________________________ Any gaps in employment and/or unemployment must be explained. Include dates (month/year) and reason. ___________________________________________________________________________________________________________ Were you subject to the federal motor carrier safety regulations (FMCSR) while employed by the previous employer? Yes no Was the previous job position designated as a safety-sensitive function in any DOT regulated mode, subject lo alcohol and controlled substances testing requirements as required by 49 CFR, Part 40? Yes no Third Last employer:___________________________________________________________________________________________ Address____________________________________________________________________Phone____________________________ Position held________________________________________________From____________To____________Salary______________ Reasons for leaving_______________________________________________________________________________ Any gaps in employment and/or unemployment must be explained. Include dates (month/year) and and reason. ___________________________________________________________________________________________________________ Were you subject to the federal motor carrier safety regulations (FMCSR) while employed by the previous employer? Yes no Was the previous job position designated as a safety-sensitive function in any DOT regulated mode, subject lo alcohol and controlled substances testing requirements as required by 49 CFR, Part 40? Yes no To be read and signed by applicant I authorize you to make sure investigations and inquiries to my personal, employment, financial or medical history and other related matters as may be necessary in arriving at an employment decision. (Generally, inquiries regarding medical history will be made only if and after a conditional offer of employment has been extended.) I hereby release employers, schools, health care providers and other persons from all liability in responding to inquiries and releasing information in connection wilh my appllcatlon. In the event of employment, I understand that false or misleading information given in my application or lnlerview(s) may result in discharge. I understand, also, that i am required to abide by all rules and regulations of the company. "I understand that information I provide regarding current and/or previous employers may be used, and those employer(s) will be contacted, for the purpose of investigating my safety performance history as required by 49 CFR 391.23(d) and (e). I understand that I have the right to: · Review information provided by current/previous employers; · Have errors in the information corrected by previous employers and for those previous employers to re-send the corrected information to the prospective employer; and · Have a rebuttal statement attached to the alleged erroneous information, if the previous employer(s) and I cannot agree on the accuracy of the information." Date_______________Applicant's Signature________________________________________________________________________ This certifies that I completed this application, and that all entries on it and information in it are true and complete lo the best of my Knowledge, Date_______________Applicant's Signature________________________________________________________________________ Note: A motor carrier may require an applicant to provide information in addition to the information required by the federal motor carrier safety regulations. Zip's Aw Direct | 316 W Milwaukee St. | New Hampton, IA 50659 2 Please fill out both sections. Request for Driving Record Name:___________________________________________________________________________________ Address:_________________________________________________________________________________ City, State, Zip Code:_______________________________________________________________________ SSN:_______________________________________Driver's License #:______________________________ Signature:______________________________________________________DOB:_____________________ Request for Driving Record Name:___________________________________________________________________________________ Address:_________________________________________________________________________________ City, State, Zip Code:_______________________________________________________________________ SSN:_______________________________________Driver's License #:______________________________ Signature:______________________________________________________DOB:_____________________ Zip's Aw Direct | 316 W Milwaukee St. | New Hampton, IA 50659 3 Drug and Alcohol Policy Purpose It is the policy of Zip's Aw Direct (herein referred to as Company) that its drivers be free of substance and alcohol abuse. Consequently, the use of illegal drugs by drivers is prohibited. Further, drivers shall not use alcohol or engage in "prohibited conduct" as defined herein. The overall goal of this policy is to ensure a drug- and alcohol~free transportation environment and to reduce accidents, injuries and fatalities. Consequences of Policy Violation Any driver who becomes unqualified or engages in prohibited conduct as set forth herein may be subject to termination of employment. Prohibited Conduct The following shall be considered "prohibited conduct" for purposes of this policy: · No driver shall report for duty or remain on duty while having an alcohol concentration of .04 or greater. · No driver shall be on duty or operate a commercial motor vehicle while the driver possesses alcohol unless the alcohol is manifested and transported as part of a shipment. · No driver shall use alcohol while performing safety-sensitive functions. · No driver shall perform safety-sensitive functions within four (4) hours after using alcohol. · No driver required to take a post-accident alcohol test shall use alcohol for eight (8) hours following an accident or until he or she undergoes a post-accident alcohol test, whichever occurs first. · No driver shall refuse to submit to a post-accident, random, reasonable suspicion, return-to-duty or follow-up alcohol or drug test. · · No driver shall report for duty or remain on duty when the driver uses any controlled substance, except when use is pursuant to the instructions of a physician who has advised the driver that the substance does not adversely affect the driver's ability to operate a commercial motor vehicle. If a driver engages in prohibited conduct, the driver is not qualified to drive a commercial motor vehicle and shall be immediately removed from service. The company may, in its discretion, at the request of the driver, keep the driver's position open while such driver attempts to become requalified. The Company may also take action against the driver up to and including termination. Refusal to Test Refusal to submit to the type of drug and alcohol tests employed by the company will be grounds for refusal to hire driver/ applicants and to terminate employment of existing driver. A refusal to test is defined to be conduct that would obstruct the proper administration of a test. Refusing to sign step 2 of the alcohol form is considered a refusal to test. A delay in providing a urine, breath or saliva specimen could be considered a refusal. If a driver cannot provide a sufficient quantity of urine or breath, he/she will be evaluated by a physician of the company's choice. If the physician cannot find a legitimate medical explanation for the inability to provide a specimen (either breath or urine, it will be considered a refusal to test. In that circumstance, the driver has violated one of the prohibitions of regulations. Types of Tests Pursuant to regulations promulgated by the Department of Transportation (DOT), the Company has implemented six circumstances for drug and alcohol testing: (1) pre-employment (drug testing only) (2) post-accident testing (3) random testing (4) reasonable suspicion testing (5) return-to-duty testing (6) follow-up testing Pre-Employment Testing All applicants for driving positions must submit to urine drug tests. A driver/applicant is not required to submit to a urine drug test if (1) the Company can verify that the driver has participated in a valid drug testing program within the preceding thirty (30) days; (2) while participated in that program, was either tested within the past six (6) months or participated in a random selection program for the previous twelve (12) months; and (3) no prior employer has knowledge that the driver violated any part of the regulations within the last six months. Random Testing The Company conducts random drug and alcohol testing. The Company or its agents will submit all drivers' names to a random selection system. Random selections will be reasonably spread throughout the year. The Company will drug test, at a minimum, 50 percent of the average number of driver positions in each calendar year at a rate established by the DOT for the given year. The company will select, at a minimum, 25 percent of the average number of driver positions in each calendar year for random alcohol testing, or at the rate established by the DOT for a given year. Random selection, by its very nature, may result in drivers being selected in successive selections or more than once a calendar year. Alternatively, some drivers may not be selected in a calendar year. Zip's AW Direct | 316 W Milwaukee St. | New Hampton, IA 50659 4 If a driver is selected at random, for either drug or alcohol testing, a Company official will notify the driver. Once notified, every action the driver takes must lead to a collection. If the driver engages in conduct that does not lead to a collection as soon as possible after notification, such conduct may be considered a refusal to test. Post-Accident Testing The driver must submit to drug and alcohol testing any time he or she is involved in an accident where (1) a fatality is involved; (2) the driver receives a citation for a moving violation arising from the accident, and any party involved requires immediate treatment for an injury away from the accident scene, or if any vehicle involved incurs "disabling damage" (i.e., must he towed away). Following any accident, the driver must contact the Company as soon as possible. The driver has been presented with an information card setting forth certain instructions for post-accident drug and alcohol testing. The driver shall follow the instruction contained on the information card as well as any additional instructions from the Company or its representatives. Any time a post-accident or drug or alcohol test is required, it must be performed as soon as possible following the accident. If no alcohol test can be made within (8) hours, attempts to perform an alcohol test shall cease. If no urine collection can be obtained for purposes of post-accident drug testing within thirty-two (32) hours, attempts to make such collection shall cease. In the event that federal, state or local officials conduct breath or blood tests for the use of alcohol and/or urine tests for the use of controlled substances following an accident, these tests may meet the requirements of this section, provided the tests conform to applicable federal, state, or local requirements. The Company may request testing documentation from such agencies and may ask the employee to sign a release allowing the Company to obtain such test results. In the event a driver is so seriously injured that the driver cannot provide a sample of urine, breath or saliva at the time of the accident, the driver may provide necessary authorization for the Company to obtain hospital records or other documents that would indicate the presence of controlled substances or alcohol in the driver's system at the time of the accident. Reasonable Suspicion Testing Reasonable suspicion for requiring a driver to submit to drug and/or alcohol testing shall be deemed to exist when a driver manifests physical or behavioral symptoms or reactions commonly attributed to the use of controlled substances or alcohol. Such driver conduct must be witnessed by at least one supervisor trained in compliance with 382.603. Should a supervisor observe such symptoms or reaction, the driver must submit to testing. Substance Abuse Evaluation, Return to Duty and Follow-Up Testing Any driver who engages in prohibited conduct shall be provided with the names, addresses and telephone numbers of qualified substance abuse professionals (SAPs). If the driver desires to become requalified, the driver must be evaluated by a SAP and submit to any treatment the SAP prescribes. Following evaluation and treatment, if any, in order to become requalified, the driver must submit to and successfully complete a return-to duty drug/or alcohol test. Such driver is also subject to follow-up testing. Follow-up testing is separate from and in addition to the Company's reasonable suspicion, post-accident and random testing procedures. The schedule for follow-up testing shall be unannounced and in accordance with the instructions of the SAP. Follow-up testing may continue for a period of up to sixty (60) months following the drivers return to duty. No fewer than six (6) tests shall be performed in the first twelve (12) months of follow-up testing. The costs of any SAP evaluation or prescribed treatment shall be borne by the driver. The Company does not guarantee or promise a position to the driver should he/she regain qualified status. Authorization for Previous Test Records Within 14 days of performing a safety-sensitive function, DOT regulations require that the Company obtain certain drug and alcohol testing records from driver's previous employers for the previous two years. The Company will verify that no prior employer of the driver has records indicating a violation of any DOT rule pertaining to controlled substance or alcohol use within the previous two (2) years. As a condition to employment, the driver shall provide the Company with a written authorization for all previous employers within the past two years to release such drug and alcohol testing records, as the regulations require. Drug Urinalysis Drug testing will be performed through urinalysis will test for the presence of drugs and/or metabolites of the following controlled substances: (1) marijuana; (2) cocaine; (3) opiates; (4) amphetamines; and (5) phencyclidine (PCP). The urinalysis procedure starts with the collection of urine specimen. Urine specimens will be submitted to a SAMHSA-certi:fied laboratory for testing. As part of the collection process, the specimen provided will be split into two vials; a primary vial and a secondary vial. The SAMHSA-certified laboratory will perform initial screenings on all primary vials. In the event that the primacy specimen tests positive, a confirmation test of that specimen will be performed before being reported by the laboratory to the MRO as a positive. All laboratory results will be reported by the laboratory to a Medical Review Officer (MRO) designated by the Company. Zip's AW Direct | 316 W Milwaukee St. | New Hampton, IA 50659 5 Negative test results shall be reported by the MRO to the Company. Before reporting a positive test result to the Company, the MRO will attempt to contact the driver to discuss the test results. If the MRO is unable to contact the driver directly, the MRO will contact the Company management official designated in advance by the Company, who shall, in turn, contact the driver and direct the driver to contact the MRO. Upon being so directed, the driver shall contact the MRO immediately or, if after the MRO's business hours and the MRO is unavailable, at the start of the MRO's nest business day. In the MRO's sole discretion, a determination will be made as to whether a result is positive or negative. If, after failing to contact the MRO after 5 days or if the driver cannot be contacted at all within 30 days, the MRO may verify the test as positive. After any positive verification the driver may petition the MRO to reopen the case for reconsideration. Pursuant to DOT regulations, individual test results for driver/applicants and drivers will be released to the Company and will be kept strictly confidential unless consent for the release of the test has been obtained. Any individual who has submitted to drug testing in compliance with this policy is entitled to receive the results of such testing upon timely written request. An individual testing positive may make a request of the MRO to have the secondary vial tested. A different SAMHSA-certified lab must test the secondary vial than tested the primary specimen. The individual making the request for a test of the second specimen must pre-pay all costs associated with the test. The request for testing of a secondary specimen is timely if it is made to the MRO within 72 hours of the individual being notified by the Company of a positive test result. Alcohol Test The Company will perform alcohol testing using a device that is on the National Highway Traffic Safety Administration's (NHTSA) Conforming Products List (CPL) and meets the DOT's testing requirements. This may be a breath testing device or a saliva-based testing device and may be provided through a vendor or agent. A technician who is certified will operate the device and trained on the specific device he or she will be operating. The driver shall report to the alcohol-testing site as notified by the Company. The driver shall follow all instructions given by the alcohol technician. Any initial test indicating a blood alcohol concentration (BAC) of .02 of greater will be confirmed on an evidential breath testing device (EBT) operated by a breath alcohol technician (BAT). The confirmation test will be performed no sooner than 15 minutes and no later than 30 minutes following the completion of the initial test. In the event the confirmation test indicates a BAC of .02 to .0399, the driver shall be removed from duty for 24 hours or until his/her next scheduled on-duty time, whichever is longer. Drivers with tests indicating a BAC of .04 of greater are considered to have engaged in prohibited conduct, which may result in disciplinary action up to and including termination. All alcohol tests shall be performed just prior to, during or just after duty. Training The Company shall ensure supervisors designed to determine whether or not reasonable suspicion exists to require a driver to undergo testing under 382.307 receive at least 60 minutes of training on recognizing alcohol misuse, and receive at least 60 minutes of training on recognizing controlled substances use. The training shall cover the physical, behavioral, speech and performance indicators of probable alcohol misuse and use of controlled substances. Educational Materials The Company shall provide educational materials that explain the requirements of 382.601, consequences of violating the regulations, and the employer's policies and procedures with the respect to meeting the requirements. The materials supplied to drivers may include information on additional employer policies with respect to the use or possession of alcohol or controlled substances, for example, the consequences for a driver found to have a specified alcohol or controlled substances level based on the employer's authority independent of 382.601. The Company shall ensure each driver is required to sign a statement certifying that he or she has received a copy of these materials described in 382.60l. This policy is not intended nor should it be construed as a contact between the Company and the employee. This policy may be changed at any time at the sole discretion of the Company. Please read, date and sign: Date_________________Signature______________________________________________ Zip's AW Direct | 316 W Milwaukee St. | New Hampton, IA 50659 6 Notification for Controlled. Substances and Alcohol Testing Part 382.113 Requirement for Notice Before performing an alcohol or controlled substances test under this part, each employer shall notify a driver-applicant that the alcohol or controlled substance test is required by this part. No employer shall falsely represent that a test is administered under this part. I understand that as required by Federal Motor Carrier Safety Administration Regulations, Title 49 Code of Federal Regulations, concerning controlled substances and alcohol testing, I will be tested for controlled substances and/or alcohol as indicated by the situation(s) stated: ___ Pre-employment for controlled substances (Part 382.301) ___ Random testing for controlled substances (Part 382.305) ___ Random testing for alcohol (Part 382.305) ___ Post-Accident testing for controlled substances and alcohol (Part 382.307) ___ Reasonable Suspicion testing for controlled substances and alcohol (Part 382.307) ___ I consent to the urine sample collection and testing for controlled substances. ___ I consent to the saliva and/or breath sample collection and testing for alcohol. I understand that a positive test result for controlled substances will render me unqualified to operate a commercial motor vehicle. I understand that a positive alcohol test from .02 to .039 will render me unqualified to drive a commercial motor vehicle for 24 hours. I understand that a positive alcohol test of .04 or greater will render me unqualified to operate a commercial motor vehicle. The medical review officer (MRO) will maintain the results of my test. Negative and positive results will be reported to the employer. If the results are positive, the controlled substance(s) will be identified. Alcohol test results will be maintained by the employer. The results will not be released to any other parties without my written authorization. I understand the above conditions and hereby agree to comply with them. ______________________________________________ (Applicant/Driver Name - Print) _________ / _____ / _____ Month Day Year ______________________________________________ (Applicant/Driver Name Signature) Zip's AW Direct | 316 W Milwaukee St. | New Hampton, IA 50659 7 Release & Documentation of Pre-Employment Testing Information By Applicant/ Driver Required By 40.25(j). PART 40.25(j) requires Employers to ask Applicant/Driver whether he or she has tested positive or refused to test on any Pre-employment alcohol or drug test administered by an Employer to which the Applicant/ Driver applied, but did not obtain safety-sensitive transportation work covered by DOT agency alcohol and drug testing rules during the past (2) years. NAME_____________________________________________________________DATE__________________________ SOCIAL SECURITY # ____________________ Applicant / Driver to answer items listed below. During the past two (2) years, have you tested positive on a Pre-employment alcohol or drug test administered by an Employer in which you applied for, but did not obtain safety-sensitive transportation work covered by Department of Transportation (DOT) drug and alcohol testing rules? YES______NO______ During the past two (2) years, have you refused to test on a Pre-employment alcohol or drug test administered by an Employer in which you applied for, but did not obtain safety-sensitive transportation work covered by Department of Transportation (DOT) drug and alcohol testing rules? YES______NO______ If you answered YES to either of the questions above, please explain below and provide documentation of your successful completion of the return-to-duty process required by Part 40, Subpart O. _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ Date_______________Name (printed)__________________________________________________________________ Signature of Applicant/ Driver__________________________________________________________________________ Witness___________________________________________________________________________________________ Zip's AW Direct | 316 W Milwaukee St. | New Hampton, IA 50659 8 Recordkeeping If "YES" to either question, retain on file for 5 years If "NO" to either question , discard after employment terminates Prior employer Check 49 CFR 391.23 Good Faith Effort 1. Call prior employer(s) and record person who was contacted. Fax the required release. Go to step 2. 2. Call prior empleyer(s) and record person who was contacted. Ask if they received the fax. If they say YES, ask for the information that is required. If the prior employer refuses to release the information, record it below and file with the driver's original release of information. Driver Name Prior Employer Address City, State, Zip Phone Number Social Security Number Fax Number Date of Contact Method 1. Notes Name of Contact Telephone Fax Email Date of Contact Method 2. Notes Name of Contact Telephone Fax Email Conducted by Title Date Zip's AW Direct | 316 W Milwaukee St. | New Hampton, IA 50659 9 CDL HOLDERS The Clearinghouse rule requires FMCSA-regulated employers, medical review officers (MROs), substance abuse professionals (SAPs), consortia/third-party administrators (C/TPAs) and other service agents to report to the Clearinghouse information related to violations of the drug and alcohol regulations in 49 Code of Federal Regulations, Parts 40 and 382 by current. The Clearinghouse rule requires FMCSA-regulated employers, medical review officers (MROs), substance abuse professionals (SAPs ), consortia/third-party administrators ( C/TP As) and other service agents to report to the Clearinghouse information related to violations of the drug and alcohol regulations in 49 Code of Federal Regulations, Parts 40 and 382 by current and prospective employees and prospective employees. I, _________________ hereby provide consent to ZIPS AW DIRECT, INC., to conduct a limited query of the FMCSA Commercial Driver's License Drug and Alcohol Clearinghouse (Clearinghouse) to determine whether drug or alcohol violation information about me exists in the Clearinghouse. I consent to ZIPS AW DIRECT, INC., running an unlimited amount of limited queries during the scope of my employment. I understand that if the limited query conducted by ZIPS AW DIRECT, INC., indicates that drug or alcohol violation information about me exists in the Clearinghouse, FMCSA will not disclose that information to ZIPS AW DIRECT, INC., without first obtaining additional specific consent from me. I further understand that if I refuse to provide consent for ZIPS AW DIRECT, INC., to conduct a limited query of the Clearinghouse, ZIPS AW DIRECT, INC., must prohibit me from performing safety-sensitive functions, including driving a commercial motor vehicle, as required by FMCSA's drug and alcohol program regulations. _________________________________________________________________________________________________ Employee Signature Date _________________________________________________________________________________________________ Email Address Zip's AW Direct | 316 W Milwaukee St. | New Hampton, IA 50659 10Adobe PDF Library 15.0 Adobe InDesign 15.1 (Windows)