Driver's application for employment

Applicant Name: *     Date of Applicatiion:  



Company:Advanced Transportation System



Addres:7350 W. 103rd Str.


City:      Bridgeview ,    State:      IL,   Zip      60455



In compliance with Federal and State equal employment opportunity laws, qualified applicants are considered for all positions without regard to race, color, religion, sex, national origin, age, marital status, veteran status, non-job related disability, or any other protected group status.


TO BE READ AND SIGNED BY APPLICANT


I hereby authorize release of information from my Department of Transportation regulated drug and alcohol testing records by my previous employer listed in Section IA, to the employer listed. This release is in accordance with DOT regulation 49 CFR Part 40, Section25. I understand that information to be released in Section II-A by my previous employer, is limited to the following items in for the past two years:


  1. 1. Alcohol tests with a result of 0.04 or higher
  2. 2. Verified positive drug tests;
  3. 3. Refusals to be tested;
  4. 4. Other violations of DOT agency drug and alcohol testing regulations.
  5. 5. Documentation, if any, of completion of the return-to-duty process following a rule violation;
  6. 6. Information obtained from previous employers of a drug and alcohol rule violation.

Signature: signature /

Date of Application:



FOR COMPANY USE ONLY:



procces record:


applicant hired:


rejected:



date employed:


point employed:



departament:


classification:



(IF REJECTED, SUMMARY REPORT OF REASONS SHOULD BE PLACED IN FILE)

Signature of interviewing officer:




termination of emloyment:


date terminated:



department released from:


termination reason:



voluntarily quit:


file:



supervisor:



This form is made available with the understanding that J. J. Keller & Associates, Inc.® is not engaged in rendering legal, accounting, or other professional services. J. J. Keller & Associates, Inc.© assumes no responsibility for the use of this form or any decision made by an employer which may violate local, state or federal law.

Positions(s) Applied for


Name

 
Last, First, Middle

SOCIAL SECURITY NUMBER: --



CELL PHONE:

E-Mail:

List your addresses of residency for the past 3 years:


Current Address:


Street:*

City:*

State:*

Zip code:*

Phone:

How Long?*

Do you have the legal right to work in the United States?


Date of birth:*

Can you provide proof of age?


Have worked for this company before? No

Who referred you?

Rate of pay expected


Have you ever been bonded? No

Is there any reason you might be unable to perform the functions of the job for which you have applied [as described in the attached job description]? No


ACCIDENT RECORD TRAFFIC CONVICTIONS FOR PAST 3 YEARS OR MORE


None

None

None

TRAFFIC CONVICTIONS

and forfeitures for the past 3 years or more. ( write NONE if none, or type in EXTRA if more space is needed)



None

None

None

EXPERIENCE AND QUALIFICATIONS - DRIVER

CDL #:

State:

Class:

Endorsement(s):

CDL School:

CDL Date:


A: Have you ever been denied a license, permit, or privilege to operate a motor vehicle? No


B: Has any license, permit, or privilege ever been suspended or revoked? No


CDL #:

State:

Class:

Endorsement(s):

CDL School:

CDL Date:


A: Have you ever been denied a license, permit, or privilege to operate a motor vehicle? No


B: Has any license, permit, or privilege ever been suspended or revoked? No



- Do you have a DUI or DWI on your driving record?* No


- Do you have any felony convictions?* No

DRIVING EXPERIENCE

CLASS OF EQUIPMENT

AMOUNT OF EXPERIENCE

APPROX. NO. OF MILES(TOTAL)

53' DRY VAN




53' REEFER




FLATBED




OVER THE ROAD




REGIONAL




LOCAL




OTHER






TO BE READ AND SIGNED BY APPLICANT

This certifies that this application was completed by me, and that all entries on it and information in it are true and complete to the best of my knowledge.

SIGNATURE

signature

DATE




SIGNATURE


THE BELOW DISCLOSURE AND AUTHORIZATION LANGUAGE IS FOR MANDATORY USE BY ALL ACCOUNT HOLDERS

IMPORTANT DISCLOSURE REGARDING BACKGROUND REPORTS FROM THE PSP Online Service


In connection with your application for employment with _Advance Transportation Systems_(“Prospective Employer”), Prospective Employer, its 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).

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.

The Prospective Employer cannot obtain background reports from FMCSA without your authorization.

AUTHORIZATION

If you agree that the Prospective Employer may obtain such background reports, please read the following and sign below:

I authorize _Advance Transportation Systems_ (“Prospective Employer”) 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.

Name:  


Signature:

signature//

Date:


NOTICE: This form is made available to monthly account holders by NIC on behalf of the U.S. Department of Transportation, Federal Motor Carrier Safety Administration (FMCSA). Account holders are required by federal law to obtain an Applicant's written or electronic consent prior to accessing the Applicant's PSP report Further, account holders are required by FMCSA to use the language contained in this Disclosure and Authorization form to obtain an Applicant's consent. The language must be used in whole, exactly as provided. Further, the language on this form must exist as one stand-alone document. The language may NOT be included with other consent forms or any other language.
NOTICE: The prospective employment concept referenced in this form contemplates the definition of "employee" contained at 49 C.F.R. 383.5. LAST UPDATED 12/22/2015
signature//
 
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I authorize Advance Transportation to request my work history from my previous employers.

 
--
signature//
   


TO BE READ AND SIGNED BY APPLICANT


I hereby authorize release of information from my Department of Transportation regulated drug and alcohol testing records by my previous employer listed in Section IA, to the employer listed. This release is in accordance with DOT regulation 49 CFR Part 40, Section25. I understand that information to be released in Section II-A by my previous employer, is limited to the following items in for the past two years:


  1. 1. Alcohol tests with a result of 0.04 or higher
  2. 2. Verified positive drug tests;
  3. 3. Refusals to be tested;
  4. 4. Other violations of DOT agency drug and alcohol testing regulations.
  5. 5. Documentation, if any, of completion of the return-to-duty process following a rule violation;
  6. 6. Information obtained from previous employers of a drug and alcohol rule violation.

Signature: signature//

Date of Application:


I authorize Advance Transportation to request my work history from my previous employers.

signature//
 
--

I authorize Advance Transportation to request my work history from my previous employers.

 
--
signature//
   


TO BE READ AND SIGNED BY APPLICANT


I hereby authorize release of information from my Department of Transportation regulated drug and alcohol testing records by my previous employer listed in Section IA, to the employer listed. This release is in accordance with DOT regulation 49 CFR Part 40, Section25. I understand that information to be released in Section II-A by my previous employer, is limited to the following items in for the past two years:


  1. 1. Alcohol tests with a result of 0.04 or higher
  2. 2. Verified positive drug tests;
  3. 3. Refusals to be tested;
  4. 4. Other violations of DOT agency drug and alcohol testing regulations.
  5. 5. Documentation, if any, of completion of the return-to-duty process following a rule violation;
  6. 6. Information obtained from previous employers of a drug and alcohol rule violation.

Signature: signature//

Date of Application:


I authorize Advance Transportation to request my work history from my previous employers.

signature//
 
--

I authorize Advance Transportation to request my work history from my previous employers.

 
--
signature//
   


TO BE READ AND SIGNED BY APPLICANT


I hereby authorize release of information from my Department of Transportation regulated drug and alcohol testing records by my previous employer listed in Section IA, to the employer listed. This release is in accordance with DOT regulation 49 CFR Part 40, Section25. I understand that information to be released in Section II-A by my previous employer, is limited to the following items in for the past two years:


  1. 1. Alcohol tests with a result of 0.04 or higher
  2. 2. Verified positive drug tests;
  3. 3. Refusals to be tested;
  4. 4. Other violations of DOT agency drug and alcohol testing regulations.
  5. 5. Documentation, if any, of completion of the return-to-duty process following a rule violation;
  6. 6. Information obtained from previous employers of a drug and alcohol rule violation.

Signature: signature//

Date of Application:


I authorize Advance Transportation to request my work history from my previous employers.

signature//
 
--

I authorize Advance Transportation to request my work history from my previous employers.

 
--
signature//
   


TO BE READ AND SIGNED BY APPLICANT


I hereby authorize release of information from my Department of Transportation regulated drug and alcohol testing records by my previous employer listed in Section IA, to the employer listed. This release is in accordance with DOT regulation 49 CFR Part 40, Section25. I understand that information to be released in Section II-A by my previous employer, is limited to the following items in for the past two years:


  1. 1. Alcohol tests with a result of 0.04 or higher
  2. 2. Verified positive drug tests;
  3. 3. Refusals to be tested;
  4. 4. Other violations of DOT agency drug and alcohol testing regulations.
  5. 5. Documentation, if any, of completion of the return-to-duty process following a rule violation;
  6. 6. Information obtained from previous employers of a drug and alcohol rule violation.

Signature: signature//

Date of Application:


I authorize Advance Transportation to request my work history from my previous employers.

signature//
 
--

I authorize Advance Transportation to request my work history from my previous employers.

 
--
signature//
   


TO BE READ AND SIGNED BY APPLICANT


I hereby authorize release of information from my Department of Transportation regulated drug and alcohol testing records by my previous employer listed in Section IA, to the employer listed. This release is in accordance with DOT regulation 49 CFR Part 40, Section25. I understand that information to be released in Section II-A by my previous employer, is limited to the following items in for the past two years:


  1. 1. Alcohol tests with a result of 0.04 or higher
  2. 2. Verified positive drug tests;
  3. 3. Refusals to be tested;
  4. 4. Other violations of DOT agency drug and alcohol testing regulations.
  5. 5. Documentation, if any, of completion of the return-to-duty process following a rule violation;
  6. 6. Information obtained from previous employers of a drug and alcohol rule violation.

Signature: signature//

Date of Application:


I authorize Advance Transportation to request my work history from my previous employers.

signature//
 
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I authorize Advance Transportation to request my work history from my previous employers.

 
--
signature//
   


TO BE READ AND SIGNED BY APPLICANT


I hereby authorize release of information from my Department of Transportation regulated drug and alcohol testing records by my previous employer listed in Section IA, to the employer listed. This release is in accordance with DOT regulation 49 CFR Part 40, Section25. I understand that information to be released in Section II-A by my previous employer, is limited to the following items in for the past two years:


  1. 1. Alcohol tests with a result of 0.04 or higher
  2. 2. Verified positive drug tests;
  3. 3. Refusals to be tested;
  4. 4. Other violations of DOT agency drug and alcohol testing regulations.
  5. 5. Documentation, if any, of completion of the return-to-duty process following a rule violation;
  6. 6. Information obtained from previous employers of a drug and alcohol rule violation.

Signature: signature//

Date of Application:


I authorize Advance Transportation to request my work history from my previous employers.

signature//
 
--

I authorize Advance Transportation to request my work history from my previous employers.

 
--
signature//
   


TO BE READ AND SIGNED BY APPLICANT


I hereby authorize release of information from my Department of Transportation regulated drug and alcohol testing records by my previous employer listed in Section IA, to the employer listed. This release is in accordance with DOT regulation 49 CFR Part 40, Section25. I understand that information to be released in Section II-A by my previous employer, is limited to the following items in for the past two years:


  1. 1. Alcohol tests with a result of 0.04 or higher
  2. 2. Verified positive drug tests;
  3. 3. Refusals to be tested;
  4. 4. Other violations of DOT agency drug and alcohol testing regulations.
  5. 5. Documentation, if any, of completion of the return-to-duty process following a rule violation;
  6. 6. Information obtained from previous employers of a drug and alcohol rule violation.

Signature: signature//

Date of Application:


I authorize Advance Transportation to request my work history from my previous employers.

signature//
 
--

I authorize Advance Transportation to request my work history from my previous employers.

 
--
signature//
   


TO BE READ AND SIGNED BY APPLICANT


I hereby authorize release of information from my Department of Transportation regulated drug and alcohol testing records by my previous employer listed in Section IA, to the employer listed. This release is in accordance with DOT regulation 49 CFR Part 40, Section25. I understand that information to be released in Section II-A by my previous employer, is limited to the following items in for the past two years:


  1. 1. Alcohol tests with a result of 0.04 or higher
  2. 2. Verified positive drug tests;
  3. 3. Refusals to be tested;
  4. 4. Other violations of DOT agency drug and alcohol testing regulations.
  5. 5. Documentation, if any, of completion of the return-to-duty process following a rule violation;
  6. 6. Information obtained from previous employers of a drug and alcohol rule violation.

Signature: signature//

Date of Application:


I authorize Advance Transportation to request my work history from my previous employers.

signature//
 
--

I authorize Advance Transportation to request my work history from my previous employers.

 
--
signature//
   


TO BE READ AND SIGNED BY APPLICANT


I hereby authorize release of information from my Department of Transportation regulated drug and alcohol testing records by my previous employer listed in Section IA, to the employer listed. This release is in accordance with DOT regulation 49 CFR Part 40, Section25. I understand that information to be released in Section II-A by my previous employer, is limited to the following items in for the past two years:


  1. 1. Alcohol tests with a result of 0.04 or higher
  2. 2. Verified positive drug tests;
  3. 3. Refusals to be tested;
  4. 4. Other violations of DOT agency drug and alcohol testing regulations.
  5. 5. Documentation, if any, of completion of the return-to-duty process following a rule violation;
  6. 6. Information obtained from previous employers of a drug and alcohol rule violation.

Signature: signature//

Date of Application:


I authorize Advance Transportation to request my work history from my previous employers.

signature//
 
--

I authorize Advance Transportation to request my work history from my previous employers.

 
--
signature//
   


TO BE READ AND SIGNED BY APPLICANT


I hereby authorize release of information from my Department of Transportation regulated drug and alcohol testing records by my previous employer listed in Section IA, to the employer listed. This release is in accordance with DOT regulation 49 CFR Part 40, Section25. I understand that information to be released in Section II-A by my previous employer, is limited to the following items in for the past two years:


  1. 1. Alcohol tests with a result of 0.04 or higher
  2. 2. Verified positive drug tests;
  3. 3. Refusals to be tested;
  4. 4. Other violations of DOT agency drug and alcohol testing regulations.
  5. 5. Documentation, if any, of completion of the return-to-duty process following a rule violation;
  6. 6. Information obtained from previous employers of a drug and alcohol rule violation.

Signature: signature//

Date of Application:


I authorize Advance Transportation to request my work history from my previous employers.

signature//
 
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I authorize Advance Transportation to request my work history from my previous employers.

 
--
signature//
   


TO BE READ AND SIGNED BY APPLICANT


I hereby authorize release of information from my Department of Transportation regulated drug and alcohol testing records by my previous employer listed in Section IA, to the employer listed. This release is in accordance with DOT regulation 49 CFR Part 40, Section25. I understand that information to be released in Section II-A by my previous employer, is limited to the following items in for the past two years:


  1. 1. Alcohol tests with a result of 0.04 or higher
  2. 2. Verified positive drug tests;
  3. 3. Refusals to be tested;
  4. 4. Other violations of DOT agency drug and alcohol testing regulations.
  5. 5. Documentation, if any, of completion of the return-to-duty process following a rule violation;
  6. 6. Information obtained from previous employers of a drug and alcohol rule violation.

Signature: signature//

Date of Application:


I authorize Advance Transportation to request my work history from my previous employers.

signature//
 
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I authorize Advance Transportation to request my work history from my previous employers.

 
--
signature//
   


TO BE READ AND SIGNED BY APPLICANT


I hereby authorize release of information from my Department of Transportation regulated drug and alcohol testing records by my previous employer listed in Section IA, to the employer listed. This release is in accordance with DOT regulation 49 CFR Part 40, Section25. I understand that information to be released in Section II-A by my previous employer, is limited to the following items in for the past two years:


  1. 1. Alcohol tests with a result of 0.04 or higher
  2. 2. Verified positive drug tests;
  3. 3. Refusals to be tested;
  4. 4. Other violations of DOT agency drug and alcohol testing regulations.
  5. 5. Documentation, if any, of completion of the return-to-duty process following a rule violation;
  6. 6. Information obtained from previous employers of a drug and alcohol rule violation.

Signature: signature//

Date of Application:


I authorize Advance Transportation to request my work history from my previous employers.

signature//
 
--

I authorize Advance Transportation to request my work history from my previous employers.

 
--
signature//
   


TO BE READ AND SIGNED BY APPLICANT


I hereby authorize release of information from my Department of Transportation regulated drug and alcohol testing records by my previous employer listed in Section IA, to the employer listed. This release is in accordance with DOT regulation 49 CFR Part 40, Section25. I understand that information to be released in Section II-A by my previous employer, is limited to the following items in for the past two years:


  1. 1. Alcohol tests with a result of 0.04 or higher
  2. 2. Verified positive drug tests;
  3. 3. Refusals to be tested;
  4. 4. Other violations of DOT agency drug and alcohol testing regulations.
  5. 5. Documentation, if any, of completion of the return-to-duty process following a rule violation;
  6. 6. Information obtained from previous employers of a drug and alcohol rule violation.

Signature: signature//

Date of Application:


I authorize Advance Transportation to request my work history from my previous employers.

signature//
 
--

I authorize Advance Transportation to request my work history from my previous employers.

 
--
signature//
   


TO BE READ AND SIGNED BY APPLICANT


I hereby authorize release of information from my Department of Transportation regulated drug and alcohol testing records by my previous employer listed in Section IA, to the employer listed. This release is in accordance with DOT regulation 49 CFR Part 40, Section25. I understand that information to be released in Section II-A by my previous employer, is limited to the following items in for the past two years:


  1. 1. Alcohol tests with a result of 0.04 or higher
  2. 2. Verified positive drug tests;
  3. 3. Refusals to be tested;
  4. 4. Other violations of DOT agency drug and alcohol testing regulations.
  5. 5. Documentation, if any, of completion of the return-to-duty process following a rule violation;
  6. 6. Information obtained from previous employers of a drug and alcohol rule violation.

Signature: signature//

Date of Application:


I authorize Advance Transportation to request my work history from my previous employers.

signature//
 
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I authorize Advance Transportation to request my work history from my previous employers.

 
--
signature//
   


TO BE READ AND SIGNED BY APPLICANT


I hereby authorize release of information from my Department of Transportation regulated drug and alcohol testing records by my previous employer listed in Section IA, to the employer listed. This release is in accordance with DOT regulation 49 CFR Part 40, Section25. I understand that information to be released in Section II-A by my previous employer, is limited to the following items in for the past two years:


  1. 1. Alcohol tests with a result of 0.04 or higher
  2. 2. Verified positive drug tests;
  3. 3. Refusals to be tested;
  4. 4. Other violations of DOT agency drug and alcohol testing regulations.
  5. 5. Documentation, if any, of completion of the return-to-duty process following a rule violation;
  6. 6. Information obtained from previous employers of a drug and alcohol rule violation.

Signature: signature//

Date of Application:


I authorize Advance Transportation to request my work history from my previous employers.

signature//
 
--

I authorize Advance Transportation to request my work history from my previous employers.

 
--
signature//
   


TO BE READ AND SIGNED BY APPLICANT


I hereby authorize release of information from my Department of Transportation regulated drug and alcohol testing records by my previous employer listed in Section IA, to the employer listed. This release is in accordance with DOT regulation 49 CFR Part 40, Section25. I understand that information to be released in Section II-A by my previous employer, is limited to the following items in for the past two years:


  1. 1. Alcohol tests with a result of 0.04 or higher
  2. 2. Verified positive drug tests;
  3. 3. Refusals to be tested;
  4. 4. Other violations of DOT agency drug and alcohol testing regulations.
  5. 5. Documentation, if any, of completion of the return-to-duty process following a rule violation;
  6. 6. Information obtained from previous employers of a drug and alcohol rule violation.

Signature: signature//

Date of Application:


I authorize Advance Transportation to request my work history from my previous employers.

signature//
 
--

I authorize Advance Transportation to request my work history from my previous employers.

 
--
signature//
   


TO BE READ AND SIGNED BY APPLICANT


I hereby authorize release of information from my Department of Transportation regulated drug and alcohol testing records by my previous employer listed in Section IA, to the employer listed. This release is in accordance with DOT regulation 49 CFR Part 40, Section25. I understand that information to be released in Section II-A by my previous employer, is limited to the following items in for the past two years:


  1. 1. Alcohol tests with a result of 0.04 or higher
  2. 2. Verified positive drug tests;
  3. 3. Refusals to be tested;
  4. 4. Other violations of DOT agency drug and alcohol testing regulations.
  5. 5. Documentation, if any, of completion of the return-to-duty process following a rule violation;
  6. 6. Information obtained from previous employers of a drug and alcohol rule violation.

Signature: signature//

Date of Application:


I authorize Advance Transportation to request my work history from my previous employers.

signature//
 
--

I authorize Advance Transportation to request my work history from my previous employers.

 
--
signature//
   


TO BE READ AND SIGNED BY APPLICANT


I hereby authorize release of information from my Department of Transportation regulated drug and alcohol testing records by my previous employer listed in Section IA, to the employer listed. This release is in accordance with DOT regulation 49 CFR Part 40, Section25. I understand that information to be released in Section II-A by my previous employer, is limited to the following items in for the past two years:


  1. 1. Alcohol tests with a result of 0.04 or higher
  2. 2. Verified positive drug tests;
  3. 3. Refusals to be tested;
  4. 4. Other violations of DOT agency drug and alcohol testing regulations.
  5. 5. Documentation, if any, of completion of the return-to-duty process following a rule violation;
  6. 6. Information obtained from previous employers of a drug and alcohol rule violation.

Signature: signature//

Date of Application:


I authorize Advance Transportation to request my work history from my previous employers.

signature//
 
--

I authorize Advance Transportation to request my work history from my previous employers.

 
--
signature//
   


TO BE READ AND SIGNED BY APPLICANT


I hereby authorize release of information from my Department of Transportation regulated drug and alcohol testing records by my previous employer listed in Section IA, to the employer listed. This release is in accordance with DOT regulation 49 CFR Part 40, Section25. I understand that information to be released in Section II-A by my previous employer, is limited to the following items in for the past two years:


  1. 1. Alcohol tests with a result of 0.04 or higher
  2. 2. Verified positive drug tests;
  3. 3. Refusals to be tested;
  4. 4. Other violations of DOT agency drug and alcohol testing regulations.
  5. 5. Documentation, if any, of completion of the return-to-duty process following a rule violation;
  6. 6. Information obtained from previous employers of a drug and alcohol rule violation.

Signature: signature//

Date of Application:


I authorize Advance Transportation to request my work history from my previous employers.

signature//
 
--

I authorize Advance Transportation to request my work history from my previous employers.

 
--
signature//
   


TO BE READ AND SIGNED BY APPLICANT


I hereby authorize release of information from my Department of Transportation regulated drug and alcohol testing records by my previous employer listed in Section IA, to the employer listed. This release is in accordance with DOT regulation 49 CFR Part 40, Section25. I understand that information to be released in Section II-A by my previous employer, is limited to the following items in for the past two years:


  1. 1. Alcohol tests with a result of 0.04 or higher
  2. 2. Verified positive drug tests;
  3. 3. Refusals to be tested;
  4. 4. Other violations of DOT agency drug and alcohol testing regulations.
  5. 5. Documentation, if any, of completion of the return-to-duty process following a rule violation;
  6. 6. Information obtained from previous employers of a drug and alcohol rule violation.

Signature: signature//

Date of Application:


I authorize Advance Transportation to request my work history from my previous employers.

ALCOHOL AND/OR DRUG
TEST NOTIFICATION

Part 382 - Controlled Substances and Alcohol Use Testing applies to drivers of this company

§382.113 Requirement for notice.
Before performing an alcohol or controlled substances test under this part, each employer shall notify a driver that the alcohol or controlled substances test is required by this part. No employer shall falsely represent that a test is administered under this part.

Company Name: Advance Transportation System


Applicant's name:

 

You are hereby notified the following test will be administered in compilance with the Federal Motor Carrier Safety Regulations.

1. The test is scheduled:

Date:


Location:


Time:


2. Check type of test:

Alcohol Controlled Substance

3. check reason for test:

Pre-employment Random Reasonable suspicion/cause Post-accident Return to duty Follow up

4. Appointment instructions/comments:




I understand as a condition of my employement with this company, the above identified test is required.

Driver/Applicant's Signature

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Date:


Witnessed by:

Company Representative: Krystyna Gotia


Date:


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