Careers - Drivers - Owner / Operator Application

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OWNER OPERATOR APPLICATION FOR CONTRACT HAULING
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 complete this application in their own handwriting. All questions that apply to the position sought must be answered. If the answer is "none," so indicate. Be sure to show ALL employment or contracted work for the past 10 years.
Section 1. GENERAL INFORMATION
| |
Number and Street
() -
Area Code
Are you able to work? - (check all that apply):
yes no
yes no
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 offense, seriousness, nature and relevance of the offense and rehabilitation may however, be considered.

Section 2: 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.



$
  Start -
  hr./wk./mo







$
  Final -
  hr./wk./mo




$
  Start -
  hr./wk./mo







$
  Final -
  hr./wk./mo




$
  Start -
  hr./wk./mo







$
  Final -
  hr./wk./mo




$
  Start -
  hr./wk./mo







$
  Final -
  hr./wk./mo




$
  Start -
  hr./wk./mo







$
  Final -
  hr./wk./mo

Yes No
Section 3. OWNERSHIP - Complete for Individual. Partnership. Corporation or Limited Liability Company (only one)
Individual (Sole Proprietorship)
(Indicate "Doing Business As" name in section 5)

Fedral Employer Identification Number (EIN)
(If none, leave blank - do not enter social security number)
Required →

Partnership
Corporation
Limited Liability Company


Fedral Employer Identification Number (EIN)
Corporation, Partnership or Certificate of Qualifications Number Issued by California Secretary of State or other governing body of the state in which your company is based.
Letter

← Numbers Only →
Section 4. PRINCIPAL PLACE OF BUSINESS








() -
Section 5. DOING BUSINESS AS (DBA) - Trade names on file with Secretary of State, or Fictitious Business Name on File with County
Doing business in: as
Doing business in: as
Doing business in: as
Section 6. TYPES OF OPERATION (check all that apply)

List Types of Operation not listed:



Section 7. EQUIPMENT
Tractor












Straight Tuck












Trailer












Section 8. OPERATING AUTHORITIES & IDENTIFICATION NUMBERS
Fedeal Identification Numbers
State Identification Numbers
and/or
PSG (for-hire passenger carriers only)
(passenger)

(passenger)
Section 9. DRIVER INFORMATION
Owner Operator:
Drivers License
Other Drivers:
Drivers License
Drivers License
Drivers License
Section 10. INSURANCE INFORMATION
List amounts of insurance carried for the following:
$ $ $
The Complete Logistics Company minimum insurance requirements are $1 million for liablility, $25,000 Trailer and $100,000 for Cargo.
If you have employees, do you have workers' Compensation Insurance?: Yes No I do not have employees
Section 11. TRAFFIC VIOLATION AND ACCIDENT RECORD
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 TYPE ACCIDENT TYPE EQUIPMENT CITY/STATE DAY or NIGHT EMPLOYER
Section 12. OTHER QUALIFICATIONS
Section 13. FOR ALL APPLICANTS - APPROVAL and AUTHORIZATION
Would you object to The Complete Logistics Company contacting your present customer(s) for a reference? Yes No
In the event that I contract for work with 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 in my system prior to contract completion and at any time during my term of contract, to the extent permitted by law. I also understand that any contract for work may be contingent upon the passing of a physical examination and a test for the presence of alcohol in my system, performed by a doctor selected by CLC. Further, I understand that at anytime after I am engaged for services, the Company may require me to submit to a physical examination and an 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 contract agreement and during the time of contracted services. I understand that should I decline to sign this consent or decline to take any of the above tests, my application to provide services may be rejected or my contract 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 investigative 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 that 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 provided on this application or any other documents filled out in connection with my contract and in any interview is true and correct. I have withheld nothing that would, if disclosed, affect this application unfavorably. I understand that if I am retained for services and any such information is later found to be false or incomplete in any respect, my contract may be voided.
No implied, oral or written agreements to the contrary to the express language of this agreement are valid unless they are in writing and signed by the President of the Company. No representative of CLC, other than the President of the Company has any authority to make any agreement contrary to the foregoing. This agreement is the entire agreement between CLC and the Independent Contractor regarding the rights of the Company or Contractor until a separate binding contract is agreed to and signed. This agreement takes the place of all-prior and contemporaneous agreements, representations and understandings of the Independent Contractor and The Complete Logistics Company. All work related decisions are based on bona fide qualifications and on-the-job performance.
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 to provide services. I have read and understand the foregoing agreement.
_________________________________________________________________________________
Section 14: CONSUMER REPORT DISCLOSURE AND DRUG RELEASE

CONSUMER REPORT DISCLOSURE AND DRUG RELEASE

In connection with my application for employment (including contract for services) with The Complete Logistics Company (CLC):

I understand that consumer reports, which may contain public record information, may be requested from DAC Services, Tulsa, Oklahoma. These reports may include the following types of information: names and dates of previous employers, reason for termination of employment, work experience, accidents, etc. 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 RESERVTION, 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 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.

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 two 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 fully 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 two-year period; and (v) the name and phone number of any substance abuse professional who evaluated me during the past two 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 questions 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 two years, and every company for which I took a pre-employment drug and/or alcohol test during the past two years.


(Applicant Name)
_________________________________________________________________
(Applicant Signature Required)


Section 15. OFFERS OF EMPLOYMENT
CLC Logo 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)

Section 16: PRE-CONTRACT PRE-DRUG TESTING AUTHORIZATION

PRE-CONTRACT PRE-DRUG TESTING AUTHORIZATION

To be considered for contract work with The Complete Logistics Company, you are required to authorize its medical representative to obtain a blood and/or urinalysis test and submit to a physical or medical examination. If you refuse to submit to such test and/or examination, your application will not be considered.

The blood and/or urinalysis test shall be used to determine the presence of a controlled substance. If you are presently taking a prescribed drug(s) under the direction of your doctor, please list the drug(s) and present a statement from your doctor, which authorizes and requires such use.

I hereby authorize The Complete Logistics Company and it's agents to obtain a blood and/or urinalysis sample for the purpose of determining the presence of a controlled substance. If you are taking prescribed drug(s), list them below. If you are not taking prescribed drug(s), write "None". I understand that the results will be kept strictly confidential.


If you are taking any non-prescribed or over-the-counter drugs, list them below. If you are not taking any non-prescribed or over-the-counter drugs, write "None".


I hereby release The Complete Logistics Company and any employee and/or agent thereof from any and all claims or causes of action resulting therefrom.

_______________________________________________________


_______________________________________________________

Section 17: CLC POLICY AGAINST HARASSMENT
HUMAN RESOURCES MEMORANDUM

CLC POLICY AGAINST HARASSMENT

CLC does not tolerate harassment of our contract applicants, contractors, vendors or customers, by another contract applicant, contractor, vendor or customer. Any form of harassment on the basis of race, sex, religion, disability or any category protected by federal, state or local law is a violation of this policy and will be treated as a disciplinary matter. While it is not easy to define precisely what harassment is, it does include slurs, jokes and other uninvited verbal, graphic or physical conduct by one individual toward another.

In particular, sexual harassment includes, but is not limited to; making unwanted sexual advances and requests for sexual favors where either:
  1. Such conduct has the purpose or effect of interfering with an individual's work performance or creates an intimidating, hostile or offensive working environment; or
  2. Submission to or rejection of such conduct by an individual is used as the basis for employment decisions affecting the individual, or
  3. Submission to the suggested conduct is explicitly, or by implication, made a term or condition of contract.
Bona fide qualifications and work performance are solely the basis for work related decisions.

The Company's policy prohibiting all types of harassment applies to the use of CLC's electronic communications systems. No one may use electronic communications in a manner that may be construed by others as harassment based on race, national origin, sex, sexual orientation, age, disability, religious or political beliefs or any characteristic protected by federal, state or local law. No jokes on this basis may be transmitted over the Company's electronic communication systems. Specifically, it is against Company policy to display or transmit sexually-explicit messages, images or cartoons. Therefore, any such transmission or use of e-mail communication that may be construed as offensive or harassment to others is strictly prohibited and may constitute grounds for termination.

We encourage any contract applicant, contractor, vendor or customer who feels that he or she is a victim of harassment on any basis to immediately report the matter to any member of CLC management or the Human Resources department at the CLC corporate office. We welcome you to report harassment even if you have not told the harasser to stop. All reports of harassment will be thoroughly and discreetly investigated by a member of management who is not involved in the alleged harassment. The matter will be treated in confidence to the extent feasible.

We cannot remedy claimed harassment unless you bring these claims to the attention of management. Failure to report claims of harassment prevents us from taking steps to remedy the problem. No one will be disciplined or otherwise retaliated against as a result of making a complaint or participating in the investigation of a complaint. The Company will not tolerate any form of retaliation by any CLC personnel against anyone who in good faith reports suspected acts of harassment. Retaliation is a serious offense that can result in termination of services.

You may contact the Human Resource office directly at (800) 397-6909 extension 220 or 205. You will be asked to describe in writing the events of the complaint. All complaints will be referred to appropriate senior management. You will be contacted regarding the investigation and its results.

If, after investigating any complaint of harassment or unlawful discrimination, the Company learns that a contractor has provided false information regarding the complaint, termination of services may result.

You should also be aware that the Federal Equal Employment Opportunity Commission and the California Department of Fair Employment and Housing investigate and prosecute complaints of prohibited harassment. If you think that you have been harassed or that you have been retaliated against for resisting or complaining, you may file a complaint with the appropriate agency. The nearest office is listed in the telephone book.

CLC is committed to providing a harassment-free work environment for all. It considers harassment to be a serious offense that can result in termination of services.

I have read and understand the CLC policy against harassment and agree to comply.
_____________________________________________________________________________________


Section 18: CLC POLICY ON WORKPLACE VIOLENCE
HUMAN RESOURCES MEMORANDUM


CLC POLICY ON WORKPLACE VIOLENCE

It is the policy of The Complete Logistics Company (CLC) to promote a safe environment for all. CLC is committed to working with all to maintain a work environment free from violence, threats of violence, harassment, intimidation, and other disruptive behavior. While this kind of conduct is not pervasive at our company, no company is immune. Disruptive behavior at one time or another will affect every company.

Violence, threats, harassment, intimidation, and other disruptive behavior in our workplace will not be tolerated; that is, all reports of incidents will be taken seriously and will be dealt with appropriately. Such behavior can include oral or written statements, electronic communications, gestures, or expressions that communicate a direct or indirect threat of physical harm such as stalking and bringing weapons to the workplace. Individuals who commit such acts may be removed from the premises and may be subject to disciplinary action, criminal penalties, or both.

We need your cooperation to implement this policy effectively and maintain a safe working environment. Do not ignore violent, threatening, harassing, intimidating, or other disruptive behavior. If you observe or experience such behavior by anyone, whether they are a company employee or not, report it immediately to a supervisor or manager or reports may be made anonymously. Supervisors and managers who receive such reports should seek advice from the CLC Human Resources Office at (800) 660-9252 extension 271 regarding investigating the incident and initiating appropriate action. (PLEASE NOTE: Threats or assaults that require immediate attention by security or police should be reported first to the Safety Department or to the police at 911).

The Safety Department will support all efforts made by supervisors and CLC management in dealing with violent, threatening, harassing, intimidating or other disruptive behavior in our workplace and will monitor whether this policy is being implemented effectively. No one will be subject to retaliation or discipline as a result of reporting a threat in good faith under this policy. If you have any questions about this policy statement, please contact the Safety Director in the Safety Department at (800) 660-9252 extension 7.

I have read and understand the CLC policy against violence and agree to comply.

_____________________________________________________________________________________


Section 19: THE COMPLETE LOGISTICS COMPANY SAFETY POLICY STATEMENT
THE COMPLETE LOGISTICS COMPANY
SAFETY POLICY STATEMENT

It is the policy of CLC to make the safety and health of all those associated with the company the first consideration in operating our business. Safety and health must be a part of every operation and everyone's responsibility. Every accident interrupts the completion of a planned activity or operation - becoming a source of loss. Personal injuries or damage to property and equipment represents suffering and waste. Efficiency of any operation can be measured by its ability to control loss. With that in mind, the CLC policy on safety is that:

  • It is CLC's responsibility to ensure safe conditions, including the equipment of contract workers.

  • Every contractor bears the primary responsibility of working safely.

  • CLC intends to comply with all laws concerning the operation of the business and the health and safety of our contractors, associates and the public.

  • Safety takes precedence over expediency or shortcuts.

  • Prevention of accidents and injuries is given precedence over operating productivity.

The Safety Department has been established to help facilitate safety, not to just enforce safety. Therefore, the Safety Department has autonomous authority to implement or correct procedures and conditions that advance our safety policies as well as to monitor them.

I understand that helping to keep CLC safe is a condition of a continuing contract relationship.

_____________________________________________________________________________________


Section 20: Request for Taxpayer Identification Number and Certification
Form W-9
(Rev. August 2013)
Department of the Treasury
Internal Revenue Services
Request for Taxpayer
Identification Number and Certification
Give Form to the requester. Do not send to the IRS.
Name (as shown on your income tax return)
Business name/disregard entity name, if different from above
Check appropriate box for federal tax classification:

Individual/sole proprietor       C Corporation       S Corporation       Partnership       Trust/estate

Limited liability company. Enter the tax classification (C=C Corporation, S=S Corporation, P=partnership)▶  

Other (see instructions)▶
Exemptions
(see instructions):

Exempt Payee code (if any)
Exemption from FACTA reporting code (if any)
Address (number, street, and apt. or suite no.)
Requester's name and address (optional)
City, state, and ZIP code
List account number(s) here (optional)
Part I Taxpayer Identification Number (TIN)
Enter your TIN in the appropriate box. The TIN provided must match the name given on the "Name" line to avoid backup withholding. For individuals, this is your social security number (SSN). However, for a resident alien, sole proprietor, or disregarded entity, see the Part I instructions on page 3. For other entities, it is your employer identification number (EIN). If you do not have a number, see How to get a TIN on page 3.

Note. If the account is in more than one name, see the chart on page 4 for guidelines on whose number to enter.
Social security number
- -

Employee identification number
-
Part II Certification
Under penalties of perjury, I certify that:
  1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me), and
  2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding, and
  3. I am a U.S. citizen or other U.S. person (defined below), and
  4. The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct.
Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally, payments other than interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the instructions on page 3.
Sign
Here
Signature of
U.S. person ▶

_________________________________________________

Date ▶

General Instructions
Section references are to the Internal Revenue Code unless otherwise noted.
Future developments. The IRS has created a page on IRS.gov for information about Form W-9, at www.irs.gov/w9. Information about any future developments affecting Form W-9 (such as legislation enacted after we release it) will be posted on that page.
Purpose of Form
A person who is required to file an information return with the IRS must obtain your correct taxpayer identification number (TIN) to report, for example, income paid to you, payments made to you in settlement of payment card and third party network transactions, real estate transactions, mortgage interest you paid, acquisition or abandonment of secured property, cancellation of debt, or contributions you made to an IRA.
    Use Form W-9 only if you are a U.S. person (including a resident alien), to provide your correct TIN to the person requesting it (the requester) and, when applicable, to:
  1. Certify that the TIN you are giving is correct (or you are waiting for a number to be issued),
  2. Certify that you are not subject to backup withholding, or
  3. Claim exemption from backup withholding if you are a U.S. exempt payee. If applicable, you are also certifying that as a U.S. person, your allocable share of any partnership income from a U.S. trade or business is not subject to the withholding tax on foreign partners' share of effectively connected income, and

4. Certify that FATCA code(s) entered on this form (if any) indicating that you are exempt from the FATCA reporting, is correct.


Note. If you are a U.S. person and a requester gives you a form other than Form W-9 to request your TIN, you must use the requester's form if it is substantially similar to this Form W-9.
Definition of a U.S. person.For federal tax purposes, you are considered a U.S. person if you are:
  • An individual who is a U.S. citizen or U.S. resident alien,
  • A partnership, corporation, company, or association created or organized in the United States or under the laws of the United States,
  • An estate (other than a foreign estate), or
  • A domestic trust (as defined in Regulations section 301.7701-7).
Special rules for partnerships. Partnerships that conduct a trade or business in the United States are generally required to pay a withholding tax under section 1446 on any foreign partners' share of effectively connected taxable income from such business. Further, in certain cases where a Form W-9 has not been received, the rules under section 1446 require a partnership to presume that a partner is a foreign person, and pay the section 1446 withholding tax. Therefore, if you are a U.S. person that is a partner in a partnership conducting a trade or business in the United States, provide Form W-9 to the partnership to establish your U.S. status and avoid section 1446 withholding on your share of partnership income.
Cat. No. 10231X Form W-9 (Rev. 8-2013)
Section 21: NOTICE TO DRIVERS & CERTIFICATE OF COMPLIANCE
NOTICE TO DRIVERS
&
CERTIFICATE OF COMPLIANCE

I. NOTICE TO DRIVERS

The Commercial Motor Vehicle Safety Act of 1986 provides for a set of controls over the drivers of commercial vehicles. The law applies to all drivers operating vehicles and combinations with a Gross Vehicle Weight Rating over 26,000 pounds, and to any vehicle, regardless of weight, transporting hazardous materials.

The following provisions of this legislation became effective July 1, 1987:

  1. No driver may possess more than one license, and no motor carrier may use a driver having more than one license. A limited exception is made for drivers who are subject to non-resident licensing requirements of any state. This exemption does not apply after December 31, 1989.
  2. A driver convicted of a traffic violation (other than parking) must notify the motor carrier AND the state, which issued the license to that driver of such conviction within 30 days.
  3. Any person applying for a job as a commercial vehicle driver must inform the prospective employer of all previous employment as the driver of a commercial vehicle for the past 10 years, in addition to any other required information about the applicant's employment history.
  4. Any violation is punishable by a fine not to exceed $2,500. In addition, the Federal Motor Carrier Safety Regulations now require that a driver who loses any privilege to operate a commercial vehicle or who is disqualified from operating a commercial vehicle, must advise the motor carrier the next business day after receiving notification of such action.

II. CERTIFICATION BY DRIVER

I herby certify that I have read and understand the driver provisions of the Commercial Motor Vehicle Safety Act of 1986 that became effective on July 1, 1987.





I further certify that the above commercial vehicle license is the only one held; or that I have surrendered the following licenses to the state indicated.



_____________________________________________________________________

Original: Give to Employer
Section 22: DRIVER 7 DAY DATA SHEET
DRIVER 7 DAY DATA SHEET

FOR NEW HIRES, CASUALS and TEMPORARY DRIVERS





INSTRUCTIONS: At the time of initial employment as a driver, or when being employed occasionally, the regulations of the Department of Transportation (rule 395.8 (r) require you to furnish a statement of the amount of time worked during the last period of seven (7) consecutive days. In the spaces below, show the number of hours worked (on duty) in each of the last 7 days.

DAY 1 2 3 4 5 6 7 TOTAL
DATE
HOURS WORKED

I hereby certify that the information given above is correct to the best of my knowledge and belief, and that I was last relieved from work at:

on



_____________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

EMPLOYMENT CHECK LIST FOR CASUALS
In addition to the above information supplied by the driver, subparagraph 391.51 (d) of the Motor Carrier Safety Regulations requires that the driver qualification file for an intermittent, casual or occasional driver employed under the rules in subparagraph 391.63 must include the following:

Initial if on file
1. Medical Examiner's Certificate - The medical examiner's certificate of his physical qualification to drive a motor vehicle, or a legible photographic copy of the certificate.
 
2. Certificate of Driver's Road Test - The original of the signed road test form and the certificate of the road test issued to the driver pursuant to subparagraph 391.31 (e), or a copy of the license or certificate which the motor carrier accepted as equivalent to the driver's road test pursuant to subparagraph 391.31.
 
3. Certificate of Written Examination, Questions and Answers - The questions asked and the answers the driver gave and the certificate of written examination issued pursuant to subparagraph 391.35, or a copy of a certificate which the motor carrier accepted as equivalent to a written examination, pursuant to subparagraph 391.37.
Section 23: SAFETY PERFORMANCE HISTORY RECORDS REQUEST
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.

Employed as (job title)

From (m/y)

To (m/y)
Did he/she drive a motor vehicle for you? Yes No If yes, what type? Straight Truck  Tractor-Semitrailer  Bus 
Cargo Tank  Double/Triple  Other  (Specify) 
Eligible for rehire?: Yes No
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

to
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?

SUBMIT FORM

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  If you prefer you can click here to download a PDF version of the application to fill out, then e-mail to: jobs@logisticsinc.com
© 2015 The Complete Logistics Company - Address: 1670 S Etiwanda Ave, Ontario, CA 91761 - Phone: (909) 544-5040