Careers - Drivers - Arizona Class A/B/C Application

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Employee Referral

Temporary Service

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PLEASE READ: Please fill out all available fields, then click the submit button. Give the form time to submit, it may take up to 50 seconds to do so. After the form is submitted, A PDF of the form will open in the browser. When this happens the application has been successfully sent to the Complete Logistics Company. Once PDF opens, click "File > Save As" in the menu of your browser if you would like to save a copy.

APPLICATION FOR EMPLOYMENT

The Complete Logistics Company is an equal opportunity employer and will not discriminate on the basis of race, color, religious creed, national origin, ancestry, age, sex, physical and/or mental disability, medical condition, marital status or any other characteristic protected under state and federal law.

INSTRUCTIONS:
The applicant is to personally complete this application. All questions that apply to the position sought must be answered. If the answer is "none," so indicate. Be sure to show ALL employment for the past 10 years.

		(mm/dd/yyyy)

POSITION APPLIED FOR	EXPECTED SALARY	DATE OF APPLICATION

GENERAL INFORMATION

			\| \|
(FIRST)	(MIDDLE)	(LAST)	(SOCIAL SECURITY NUMBER)

Current Address
	(NUMBER AND STREET)	E-MAIL:	(HOME PHONE)


(CITY)	(STATE)	(ZIP CODE)	(CELL PHONE)

For checking prior records, provide other names under which you have worked:

Have you ever applied here before?

yes

If yes, give date:

Have you been employed here before?

yes

If yes, give dates:

Are you employed now?

yes

On what date would you be able to start work?:

Are you able to work? (check all that apply):

full-time

part-time

overtime

days

nights

weekends

holidays

If hired, can you show proof of age?

yes

If hired and you are under 18 years of age, can you furnish a work permit?

yes

Have you pled guilty or "no contest" to, or been convicted of any felony?

yes

If yes, what county:

If yes, give dates and details:

Have you been arrested for any matters for which you are out on bail or on your own recognizance pending trial?

yes

If yes, what county:

If yes, give dates and details:

NOTE: Do not list minor offenses, minor traffic infractions or convictions for which the record has been sealed or expunged or for convictions that have been discharged and judicially dismissed or marijuana convictions over 2 years old. Answering "yes" to these questions does not constitute an automatic bar to employment. Factors such as age, time of the offence, seriousness, nature and relevance of the offence and rehabilitation may however, be considered.

If hired, can you submit evidence of eligibility to work in the U.S.?

yes

Can you perform the requirements of this job with or without reasonable accommodation?

yes

In case of emergency notify:

(FIRST AND LAST NAME)

(PHONE NUMBER)

How did you hear about CLC?

Newspaper

Online

Signs

Employee Referral

(EMPLOYEES NAME)

Other

RECORD OF PREVIOUS EMPLOYMENT

Please list the names of your present or previous employers in chronological order with present or last employer listed first. Be sure to account for ALL periods of time for the past 10 years including military service and any period of unemployment. If self employed, give firm name and supply business references. Add additional pages if necessary.

PRESENT OR MOST RECENT EMPLOYER

Name of Company	Date Employed: From - Month/Year	Pay Rate: Starting $	Your Position or Title	Reason for Leaving
Address
City, State, Zip	To - Month/Year	Final Pay $	Your Supervisor's Name
Phone #			Supervisor's Title

Name of Company	Date Employed: From - Month/Year	Pay Rate: Starting $	Your Position or Title	Reason for Leaving
Address
City, State, Zip	To - Month/Year	Final Pay $	Your Supervisor's Name
Phone #			Supervisor's Title

Name of Company	Date Employed: From - Month/Year	Pay Rate: Starting $	Your Position or Title	Reason for Leaving
Address
City, State, Zip	To - Month/Year	Final Pay $	Your Supervisor's Name
Phone #			Supervisor's Title

Name of Company	Date Employed: From - Month/Year	Pay Rate: Starting $	Your Position or Title	Reason for Leaving
Address
City, State, Zip	To - Month/Year	Final Pay $	Your Supervisor's Name
Phone #			Supervisor's Title

Name of Company	Date Employed: From - Month/Year	Pay Rate: Starting $	Your Position or Title	Reason for Leaving
Address
City, State, Zip	To - Month/Year	Final Pay $	Your Supervisor's Name
Phone #			Supervisor's Title

Have you ever been discharged or asked to resign from any position?

Yes

If yes, please explain circumstances:

Please explain any gaps in your employment history:

Have you been in the military?

Yes

Reserve Status:

Do you have adequate transportation to and from work?

Yes

Do you have any relatives employed by this company?

Yes

If yes, give name and relationship:

In the past 3 years, how many day's work did you miss due to reasons other then paid holiday's or vacation?

(YEAR)

(NO. DAYS)

(YEAR)

(NO. DAYS)

(YEAR)

(NO. DAYS)

EDUCATION
Schools	Name and Address	Major	G.E.D./Diploma/Degree
High School
College or University
Business or Technical
Other

Please list any other special training, skills, abilities, experience, or qualifications that may be relevant to the company or job for which you are
applying:

How long have you been a resident where you currently reside?

PAST RESIDENCES - List in chronological order your previous places of residence for the past 5 years.
1. Address	City	State	Zip	From	To
2. Address	City	State	Zip	From	To
3. Address	City	State	Zip	From	To

PERSONAL REFERENCES - List persons who know you well, NOT relatives, previous employers or anyone in the service of CLC
Name	Occupation	Phone	Address
1.
2.
3.

SECTION FOR DRIVER POSITIONS

CURRENT DRIVERS LICENSE

Drivers License	STATE	LICENSE NUMBER	CLASS	ENDORSEMENTS	EXPIRATION DATE
Drivers License

Have you even been convicted of a moving violation?		Yes		No	If yes, explain:

Has your license ever been suspended or revoked?

Yes

If yes, explain:

Have you ever been denied a license?		Yes		No	If yes, explain:

TRAFFIC CONVICTIONS LAST 3 YEARS (INCLUDING PERSONAL OR OFF-DUTY INCIDENTS: IF "NONE," WRITE "NONE")

DATE	LOCATION	VIOLATION	PENALTY

ACCIDENT RECORD FOR LAST 3 YEARS (IF NONE, WRITE NONE)

MONTH/YEAR	ACCIDENT TYPE	EQUIPMENT TYPE	CITY/STATE	DAY or NIGHT	EMPLOYER

DRIVING EXPERIENCE

CLASS OF EQUIPMENT	WHERE ACQUIRED	NO. OF YEARS	APPROXIMATE MILES
STRAIGHT TRUCK
TRACTOR/TRAILER
TRACTOR/DOUBLE TRAILERS
LIST OTHERS

Expiration date of last Department of Transportation (D.O.T.) physical:

Are you familiar with D.O.T. safety regulations?

Yes

What safety awards do you hold and from whom?

List any relevant training or qualifications that you wish to have considered:

Are you familiar with OSHA safety regulations?

Yes

List any relevant training or qualifications that you wish to have considered:

SECTION FOR MAINTENANCE AND SHOP MECHANIC POSITIONS

Do you have a complete set of mechanical tools?

Yes

What types of equipment are you experienced with (i.e. International, Peterbilt, Freightliner, etc.)?

List any areas of repair that you are specialized in (i.e. carburetors, pumps, front end, etc.)

ADDITIONAL EXPERIENCE	WHERE ACQUIRED	NO. OF YEARS
AXLES & FRAME Yes No
BODY & FENDER Yes No
BRAKES Yes No
ELECTRICAL Yes No

MECHANIC AND MAINTENANCE EXPERIENCE (continued from Page 3)

SECTION FOR PROFESSIONAL - ADMINISTRATION - CLERICAL POSITIONS

PLEASE LIST THE NUMBER OF YEARS EXPERIENCE IN THE FOLLOWING AREAS
10 KEY	TOUCH TYPING?	ACCTS. PAYABLE	BILLING	RECEPTION
TYPING	WPM	ACCTS. RECEIVABLE	FINANCE	SALES
SHORTHAND	WPM	DATA PROCESSING	H.R.	SECRETARIAL
TRANSCRIPTION	ACCESS	OPERATION MGT.	I.S.	W.H. MGT.
DATA ENTRY	POWERPOINT	CREDIT/COLLECTIONS	PAYROLL	TRAFFIC
SWITCHBOARD	WORD	CUSTOMER SERVICE	CLAIMS	CERIDIAN HR
P.C.	EXCEL	CONTRACT MGT.	RATES	OTHER HR
ORACLE ACCTG.	CERIDIAN PR	TELEMARKETING	PC MILER	OTHER W.H.
OTHER ACCTG.	OTHER PR	PUBLISHER	ROADNET	OTHER TRANS.

List any relevant training or qualifications that you wish to have considered:

SECTION FOR ALL APPLICANTS - APPROVAL AND AUTHORIZATION

Can The Complete Logistics Company contact your present employer for a reference?

Yes

INITIALS

In the event of my employment to a position in The Complete Logistics Company (CLC), I understand that CLC reserves the right to require me to submit to a test for the presence of drugs/alcohol in my system prior to employment and at any time during my employment, to the extent permitted by law. I also understand that any offer of employment may be contingent upon the passing of a physical examination and a test for the presence of drugs/alcohol in my system, performed by a doctor selected by CLC. Further, I understand that at anytime after I am hired, the Company may require me to submit to a physical examination and a drugs/alcohol test, to the extent permitted by law. I consent to the disclosure of the results of any physical examination and related tests to CLC. I also understand that I may be required to take other tests such as personality and honesty tests, prior to employment and during my employment. I understand that should I decline to sign this consent or decline to take any of the above tests, my application for employment may be rejected, offer of employment may be revoked, or my employment may be terminated.

I authorize CLC and its agents to investigate my background, education, past employment and references and in this regard, to ascertain information from private individuals and firms and security organizations, from public records and from other private and public sources. I understand that CLC may investigate my driving record and my criminal record and that an investigation consumer report may be prepared whereby information is obtained through personal interviews with personal references, friends, my neighbors and others with whom I am acquainted. This inquiry includes information as to my character, general reputation, personal characteristics and mode of living. I understand that I have a right to make a written inquiry within a reasonable period of time to receive additional detailed information about the nature and scope of this investigation. I further understand the CLC may contact my previous employers and I authorize those employers to disclose to CLC all records and information pertinent to my employment with them. In addition to authorizing the release of any information regarding my employment, I hereby fully waive any rights or claims I have or may have against my former employers, their agents, employees and representatives, as well as other individuals who release information to CLC and release them from any and all liability, claims or damages that may directly or indirectly result from the use, disclosure, or release of any such information that they may have regarding myself. I further agree to indemnify and hold CLC harmless from any claims which may result from its seeking, obtaining or using the background information described above.

I hereby state that all information that I provided on this application or any other documents filled out in connection with my employment and in any interview are true and correct. I have withheld nothing that would, if disclosed, affect this application unfavorably. I understand that if I am employed and any such information is later found to be false or incomplete in any respect, I may be dismissed. I understand that if selected for hire, it would be necessary for me to provide satisfactory evidence of my identity and legal authority to work in the United States, and that federal immigration laws require me to complete an I-9 Form in this regard.

If hired, I agree as follows: My employment and compensation is terminable at-will, is for no definite period, and my employment and compensation may be terminated by CLC at any time and for any reason whatsoever, with or without good cause at the option of either the Company or myself. No implied, oral or written agreements that are contrary to the express language of this agreement are valid unless they are in writing and signed by the Principal of the Company. No supervisor, employee, or representative of CLC, other than the Principal of the Company has any authority to make any agreement contrary to the foregoing. This agreement is the entire agreement between CLC and the employee regarding the rights of the Company or employee to terminate employment with or without good cause. This agreement takes the place of all-prior and contemporaneous agreements, representations and understandings of the employee and CLC.

DO NOT SIGN UNTIL YOU HAVE READ THE ABOVE STATEMENT AND AGREEMENT. If you have any questions regarding this statement, ask a CLC representative before signing.

I certify that this application was completed by me and that the statements made herein and the answers to all the foregoing questions are true, complete and correct and are full and fair disclosures concerning my background, character and qualifications for employment. I have read and understand the foregoing agreement.

SIGNATURE

_____________________________________________________________________

DATE

RECORD OF PREVIOUS EMPLOYMENT (Continued from Page 2)

PRESENT OR MOST RECENT EMPLOYER

Name of Company	Date Employed: From - Month/Year	Pay Rate: Starting $	Your Position or Title	Reason for Leaving
Address
City, State, Zip	To - Month/Year	Final Pay $	Your Supervisor's Name
Phone #			Supervisor's Title

Name of Company	Date Employed: From - Month/Year	Pay Rate: Starting $	Your Position or Title	Reason for Leaving
Address
City, State, Zip	To - Month/Year	Final Pay $	Your Supervisor's Name
Phone #			Supervisor's Title

Name of Company	Date Employed: From - Month/Year	Pay Rate: Starting $	Your Position or Title	Reason for Leaving
Address
City, State, Zip	To - Month/Year	Final Pay $	Your Supervisor's Name
Phone #			Supervisor's Title

Name of Company	Date Employed: From - Month/Year	Pay Rate: Starting $	Your Position or Title	Reason for Leaving
Address
City, State, Zip	To - Month/Year	Final Pay $	Your Supervisor's Name
Phone #			Supervisor's Title

Name of Company	Date Employed: From - Month/Year	Pay Rate: Starting $	Your Position or Title	Reason for Leaving
Address
City, State, Zip	To - Month/Year	Final Pay $	Your Supervisor's Name
Phone #			Supervisor's Title

Name of Company	Date Employed: From - Month/Year	Pay Rate: Starting $	Your Position or Title	Reason for Leaving
Address
City, State, Zip	To - Month/Year	Final Pay $	Your Supervisor's Name
Phone #			Supervisor's Title

Name of Company	Date Employed: From - Month/Year	Pay Rate: Starting $	Your Position or Title	Reason for Leaving
Address
City, State, Zip	To - Month/Year	Final Pay $	Your Supervisor's Name
Phone #			Supervisor's Title

The COMPLETE LOGISTICS COMPANY (CLC)
CONSUMER REPORT DISCLOSURE, RELEASE AND DRUG RELEASE

In connection with my application for employment (including contract for services) with CLC:

I understand that consumer reports, which may contain public record information, may be requested from DAC Services, 4500 S. 129th E. Ave., Tulsa, Oklahoma. DAC's consumer department telephone number is 800-381-0645. These reports may include the following types of information: names and dates of previous employers, performance, reason for termination of employment, work experience, accidents, general character, reputation, mode of living, personal characteristics, etc. This information may be obtained through interviews with persons who have knowledge of such information. I further understand that such reports may contain public record information concerning my Driving Record, Workers' Compensation Claims, Credit, Bankruptcy Proceedings, Criminal Records, etc., from federal, state and other agencies which maintain such records: as well as information from DAC concerning previous driving record requests made by others from such state agencies, and state provided driving records. I AUTHORIZE, WITHOUT RESERVATION, ANY PARTY OR AGENCY CONTACTED BY DAC TO FURNISH THE ABOVE-MENTIONED INFORMATION.

I have the right to make a request to DAC, upon proper identification, to request the nature and substance of all information in its files on me at the time of my request, including the sources of information; and the recipients of any reports on me which DAC has previously furnished within a two year period preceding my request. I hereby consent to your obtaining the above information from DAC, and I agree that such information which DAC has or obtains, and my employment history with you if I am hired, will be supplied by DAC to other companies, which subscribe to DAC Services. I authorize procurement of consumer reports. If hired (or contracted), this authorization shall remain on file and shall serve as ongoing authorization for you to procure consumer reports at any time during my employment.

In conformity with sections 382.413, 382.405, and 391.89 of Title 49 of the code of Federal Regulations, I hereby authorize the carriers listed below to furnish to DAC Services (DAC) on behalf of CLC the following information concerning drug and alcohol tests, including pre-employment tests, the carriers conducted during the past three years: (i) the dates on which I tested positive for drugs, and the drug(s) involved: (ii) the dates on which I tested 0.02 or greater for alcohol and the test result levels: (iii) the dates on which I refused to be tested for drugs and/or alcohol.

I understand that the information I authorize DAC to receive involves tests which were required by the Department of Transportation (DOT), and may also include information concerning tests which DOT did not require but which the carriers listed below may have voluntarily conducted under their own authority unless I instruct the carriers in writing not to release information concerning items (I), (ii), or (iii), I also authorize that carrier to release and furnish: (iv) the dates of my negative drug and/or alcohol tests and/or tests with results below 0.02 during the three-year period; and (v) the name and phone number of any substance abuse professional who evaluated me during the past three years.

List Previous Employers - CDL Driver Positions Only	City	State	Phone Number




(Attach additional form if needed, additional forms require driver's signature.)

By signing below, I certify that I have read and fully understand this release, that prior to signing I was given an opportunity to ask ques tions and to have those questions answered to my satisfaction, and that I executed this release voluntarily and with the knowledge that the information being released could affect my being hired. I further certify that the all of the information which I have furnished on this form is true and complete, and that I have listed every company for which I worked as a driver during the past three years, and every company for which I took a pre-employment drug and/or alcohol test during the past three years.

(Applicant Name Printed)

___________________________________________________________
(Applicant Signature Required)

(Today's Date)

(Social Security No.)

(Date of Birth)

(Driver License No.)

(State of License)

Address:

Street Number

Street

City

State

Zip

Notice to California Applicants: You have the right to obtain a copy of any consumer or investigative consumer report obtained by CLC by checking the box that follows. The report will be provided to you within three (3) business days after we receive the requested reports related to the matter investigated.

I request to receive a free copy of this report by checking this box.

Under sec. 1786.22 of the California Civil Code, you may view the file maintained on you by DAC during normal business hours. You may also obtain a copy of this file upon submitting proper identification and paying the costs of duplication services, by appearing at DAC in person or by mail. You may also receive a summary of the file by telephone. The agency is required to have personnel available to explain your file to you and the agency must explain to you any coded information appearing in your file. If you appear in person, a person of your choice may accompany you, provided that this person furnishes proper identification.

IMPORTANT NOTICE
REGARDING BACKGROUND REPORTS FROM THE PSP Online Service

1. In connection with your application for employment with The Complete Logistics Company, it 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 CLC uses any information it obtains from FMCSA in a decision to not hire you or to make any other adverse employment decision regarding you, CLC 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, CLC 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 CLC uses any information it obtains from FMCSA in a decision to not hire you or to make any other adverse employment decision regarding you, CLC 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 CLC who procured the report, then, within 3 business days of receiving your request, together with proper identification, CLC must send or provide to you a copy of your report and a summary of your rights under the Fair Credit Reporting Act.

CLC cannot obtain background reports from FMCSA unless you consent in writing.

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

2. I authorize The Complete Logistics Company 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 consenting to the release of safety performance information including crash data from the previous five (5) years and inspection history from the previous three (3) years. I understand and acknowledge that this release of information may assist CLC to make a determination regarding my suitability as an employee.

3. I further understand that neither CLC 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 am challenging 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.

4. Please note: 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 FMCSR violations that have been adjudicated by a court of law will also appear, and remain, on a PSP report.

I have read the above Notice Regarding Background Reports provided to me by CLC and I understand that if I sign this consent form, CLC may obtain a report of my crash and inspection history. I hereby authorize CLC and its employees, authorized agents, and/or affiliates to obtain the information authorized above.

Date:		____________________________________________________________________________________ Signature
		Name (Please Print)

NOTICE: This form is made available to monthly account holders by NICT on behalf of the U.S. Department of Transportation, Federal Motor Carrier Safety Administration (FMCSA). Account holders are required by federal law to obtain a driver's written or electronic consent prior to accessing the driver's PSP report.

AFFIRMATIVE ACTION FORM

TO BE READ AND SIGNED BY THE APPLICANT

The Complete Logistics Company is an Equal Opportunity Employer. As required by law, we must record certain information to be made a part of our Affirmative Action Program.

Applicants are considered for all positions, and employees are treated during employment without regard to color, religion, sex, national origin, age and disability. As employers/government contractors, we comply with government regulations and Affirmative Action responsibilities.

Solely to help us comply with government record keeping, reporting and other legal requirements, please complete this form. In extending this invitation you are also advised that applicants are under no obligation to respond, but may do so if they choose; responses will remain confidential within the Human Resources Department; and responses will be used only for the necessary information to include in our Affirmative Action Program. We are a company that values diversity. We actively encourage women and minorities to apply. Please complete the information requested below. Thank you for your cooperation.

Applicant's Name:
	Last	First	Middle

Position(s) applied for:

Date:

Sex:

Male

Female

Race / Ethnicity:

	American Indian or Alaska Native		White
	Asian		Hispanic or Latino
	Black or African American		Two or more races
	Native Hawaiian or other Pacific Islander		Decline to State

Veteran / Disabled:

Veteran

Vietnam Era Veteran

Disabled Veteran

Disabled Person

Please identify where you learned about an employment opportunity with this organization:

Government agencies require reports on status of applicants. This data is for analysis and affirmative action only. Submission is voluntary. Failure to supply this information will not jeopardize or adversely affect any consideration you may receive for employment, or later advancement in employment.

We Are Union Free

Welcome to a union free organization! The Complete Logistics Company (CLC), like over 90 percent of other private businesses in the United States, is union free. This is a tribute to all of our employees who have clearly made a commitment to deal with leadership directly. There is always a chance in the future that a union organizer will ask you to sign union membership authorization cards. For this reason, it is vital for you to understand CLC's philosophy about unions.

While employees have the right to join a labor union employees also have the right not to join a union. If anyone attempts to pressure you into joining or signing a card in support of a union, you should keep in mind that state and federal regulations protect your right to say "No" to a union. Intimidation or coercion by any person concerning an individual's right to join or refrain from joining a union will not be condoned.

To say it clearly and simply, CLC believes that a union cannot offer any advantage to its employees. As a matter of fact, a union can seriously hurt the trusting relationships we have built through the years and harm the business we depend on for our livelihood and future success.

Union free environments are less costly to CLC, its customers and employees. Therefore, maintaining a union free culture allows CLC to appeal to a wide customer base and as such, create more opportunities for our employees and their families.

Our employees have successfully enjoyed working personally and directly with CLC leadership to resolve issues, rather than through third party outsiders. We feel this mutual commitment directly affects the success and stability of the company, therefore, our management philosophy revolves around mutual respect and recognition of our employee's importance to the company.

WELCOME ABOARD and join our continuing effort and belief in keeping our company union free.

If you ever have any questions about CLC's position on unions, please ask your regional manager or contact the Human Resources Department.

(Print name)
__________________________________________________________________________ (Signature)	(Date)

	OFFERS OF EMPLOYMENT
	TO BE READ AND SIGNED BY THE APPLICANT

I (APPLICANT NAME) , understand and agree that The Complete Logistics Company is under no obligation to hire me and that the granting of an interview is not intended to and does not create a contract of employment between The Complete Logistics Company and myself, nor does it constitute a promise of employment of any kind or duration.

I understand that any offer of employment that is made to me, if any, will not be valid unless it is in writing and signed by the director of Human Resources. I further understand that no employee of The Complete Logistics Company or any other person acting on its behalf has the authority to make a verbal offer of employment to me and such offers of employment, if any, have no force and effect and are not legally binding.

I understand that any verbal discussions about the terms or conditions of employment by company representatives are not binding upon The Complete Logistics Company unless confirmed in writing and signed by the director of Human Resources.

My signature below certifies that I have read, understood, and agree to the foregoing policy. My signature below further certifies that I understand that offers of employment may not be made verbally and that I cannot and will not rely on any such statements.

(Print Applicant Name)		__________________________________________________________________________ (Applicant Signature)
(Date)

THE COMPLETE LOGISTICS COMPANY
SAFETY PERFORMANCE HISTORY RECORDS REQUEST

Page 1

RECIPIENT EMPLOYER: The individual identified in SECTION 1 below has indicated that you employ(ed) or use(d) him/her within the last 3 years in a position that involved the operation of a commercial motor vehicle and/or that was subject to U.S. Department of Transportation (DOT)-regulated drug and alcohol testing.

In accordance with 49 CFR §40.25 and 391.23, we are hereby requesting that you supply us with the Safety Performance History of this individual. Under DOT rule 391.23(g), you must respond to this inquiry within 30 days of receipt.

Please complete SECTION 2 below, and page 2 SECTIONS 3 and 4 (if applicable), and then return to The Complete Logistics Company shown in SECTION 1.

APPLICANT: Complete SECTION 1 and submit to prospective employer.

SECTION 1:

TO BE COMPLETED BY PROSPECTIVE EMPLOYEE

I, (Print Name)
	First, M.I., Last	Social Security Number

	Hereby authorize:	Date of Birth

Previous Employer:			Email:
Street:			Telephone:
City, State, Zip:			Fax No.:

to release and forward the information requested by section 4 of this document concerning my Alcohol and Controlled Substance Testing records
within the previous 3 years from
	(date of employment application)

To:
Prospective Employer:	The Complete Logistics Company
Attention:	Human Resources	Telephone:	(909) 427-9800
Street:	13831 Slover Ave.
City, State, Zip:	Fontana, CA 92337

In compliance with §40.25(g) and 391.23(h), release of this information must be made in a written form that ensures confidentiality such as fax, email, or letter.
Prospective employer's confidential fax number:	(909) 428-6980
Prospective employer's confidential email address:	hrassist@logisticsinc.com


Applicant's Signature		Date

SECTION 2:

TO BE COMPLETED BY PREVIOUS EMPLOYER

EMPLOYMENT VERIFICATION
The applicant named above was or is used by us.	Yes	No

Employed as (job title)

From (m/y)

To (m/y)

Did he/she drive a motor vehicle for you?

Yes

If yes, what type?

Straight Truck

Tractor-Semitrailer

Bus

Cargo Tank

Double/Triple

Other

(Specify)

Eligible for rehire?:

Yes

Based on quality of work, safety habits, attendance and attitude how would you rate employee?:

Excellent

Good

Fair

Poor

Comments:

Completed by:

Signature:

If there is no safety performance history to report, check here and return. Otherwise, complete Sections 3 and 4 on page 2 before returning.

THE COMPLETE LOGISTICS COMPANY
SAFETY PERFORMANCE HISTORY RECORDS REQUEST

Page 2

Employee Name:

Date:

SECTION 3:

TO BE COMPLETED BY PREVIOUS EMPLOYER

ACCIDENT HISTORY

Complete the following for any accidents included on your accident register (§390.15(b)) that involved the applicant in the 3 years prior to the application date shown on PAGE 1 or check here if there is no accident register data for this driver.

	Date	Location	No.of Injuries	No. of Fatalities	Hazmat Spill
1.
2.
3.

Please provide information concerning any other commercial motor vehicle accidents involving the applicant that were reported to government agencies or insurers or retained under internal company policies:

SECTION 4:

TO BE COMPLETED BY PREVIOUS EMPLOYER

DRUG AND ALCOHOL HISTORY

If applicant was not subject to DOT testing requirements 49 CFR Part 40 while employed by you, please check here and return.

Applicant was subject to DOT testing requirements from

In answering these questions, include any required DOT drug or alcohol testing information you obtained from other employers in the 3 years prior to the application date shown on PAGE 1.

Within the past 3 years from the application date shown on PAGE 1:

1.	Has this person violated any of the drug and/or alcohol prohibitions under 49 CFR Part 40 or Subpart B of Part 382 including:
	An alcohol test with a result of 0.04 or higher alcohol concentration. A controlled substances test result of positive, adulterated, or substituted. A refusal to submit to a random, post-accident, reasonable-suspicion, or follow-up controlled substances or alcohol test. Alcohol use while performing or within 4 hours before performing safety-sensitive functions. Alcohol use after an accident, in violation of §382.303 Controlled substances use while on duty, except as allowed under §382.213	Yes	No
2.	If this person violated a DOT drug and/or alcohol prohibition, did he/she fail to begin or complete a rehabilitation program prescribed by a Substance Abuse Professional (SAP)? If rehabilitation was required but you do not know if he/she began or completed such a program, check here	Yes	No	N/A
3.	If this person successfully completed a SAP's rehabilitation referral and remained in your employ, did he/she subsequently have an alcohol test result of 4.0 or greater, a verified positive drug test, or refusal to be tested?
4.	Did a previous employer report a drug and alcohol rule violation to you?
5.	If you answered "yes" to any of the above items, did the employee complete the return-to-duty process?

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