meadow lark transport, inc. 866-736-5233 transport application - 2 of 11 the u.s. department of...

Transport Application - 1 of 11

Have you ever been convicted of a felony? Yes NoHave you ever been convicted of a DUI/DWI? Yes NoIf yes, please explain fully on a separate sheet of paper.Conviction is not an automatic bar to employment. All circumstances will be considered.A. Have you ever been denied a license, permit or privilege to operate a motor vehicle? Yes NoB. Has any license, permit or privilege ever been suspended or revoked? Yes NoC. Have you ever been disqualified for violations of the Federal Motor Carrier Safety Regulations? Yes NoIf you answered “yes” to A, B, or C; attach a statement giving details.

IN CASE OF EMERGENCY NOTIFY: Phone: Relationship:

Street: City: State: Zip:

Position applying for? Owner/Operator DriverWho referred you?Have you worked for this company before? Yes NoIf yes, dates of service:Names of any relatives employed by this company:

Are you currently employed? Yes NoIf no, how long since leaving last employment:List special courses or training that will help you as a driver:

List driving awards received and who presented them:

Print Applicant Name:

Social Security #: Phone:

Cell Phone: Fax:

Date of Birth: E-mail:

Current Street Address:

City: State: Zip Code:

If at the above residence less than three years, list below all residences for the past three years.Attach a separate sheet if necessary.






Meadow Lark Transport, Inc. Driver Application - E-mail completed form to: [email protected] or Fax to: (866) 600-9443

Headquarters935 Lake Elmo Drive

Billings, MT 59105Phone: 866-736-5233


The U.S. Department of Transportation requires that driver applications show all employment for the past three years. Effective July, 1987 they must show commercial driver employment for the seven years immediately preceding this year period. §391.21 (B) (10), (11)

WE REQUIRE 10 YEARS OF PAST EMPLOYMENT, NO GAPS ALLOWED. IF UNEMPLOYED, THEN STATE UNEMPLOYED AND THE AMOUNT OF TIME YOU WERE UNEMPLOYED. IF SELF EMPLOYED AND RUNNING UNDER YOUR OWN AUTHORITY PLEASE SUPPLY US WITH A COPY OF YOUR LAST 3 YEARS 1099’S.

Begin with last or current position, including military experience, and work back. (Attach a separate sheet if necessary)

Current Employer: Supervisors Name:

Address: Phone:

Position Held: From (mm/yyyy): To (mm/yyyy):

Reason for Leaving:

Were you subject to the FMCSRs while employed here? Yes No

Was your job designated as a safety-sensitive function in any DOT-Regulated mode subject to the drug and alcohol testing requirements of 49 CFR part 40? Yes NoTrailer type pulled: Flatbed Stepdeck RGN DD Van Reefer Other:


Address: Phone:


Reason for Leaving:




Address: Phone:


Reason for Leaving:




Address: Phone:


Reason for Leaving:



Work History

Employment Record



Address: Phone:


Reason for Leaving:




Address: Phone:


Reason for Leaving:




Address: Phone:


Reason for Leaving:




Address: Phone:


Reason for Leaving:




Address: Phone:


Reason for Leaving:



Work History continued


FOR OFFICE USE – DO NOT WRITE IN THIS SPACE

Applicant Hired? YES NO Date Employed: (If not hired, summary report of reasons should be placed in file)

TERMINATION OF EMPLOYMENT

Date Terminated: Dismissed: Voluntarily Quit: Other:

List Driver’s Licenses held in the past 3 years:

State License Number Class Endorsement(s) Exp. Date

License History

Other than parking violations list any traffic convictions or forfeitures in the last 3 years:

State Date Description

Citation History

List any accidents for the last 3 years: (attach separate sheet if needed)

Dates(Latest First)

Nature of Accident(Head-On, Rear-End, Overturn, etc.)

Fatalities Injuries

Accident Review

I certify that I have read and understand all of this application. It is agreed and understood that the lessee or his agents may investigate my background to ascertain any and all information of concern to my employment history, whether same is of record or not, and I release employers and other persons named herein from all liability for any damages on account of furnishing such information. I understand that, as a potential lessor with this company, I may be asked to demonstrate that I am capable of performing tasks which are pertinent to the job. I also understand that the lease may be conditioned on the results of a physical examination and drug test. I further certify that I am a genuine potential lessor and this application is being submitted solely for the purpose of establishing a lease with the lessee and for no other reason. It is also agreed and understood that under the fair credit reporting act, public law 91-508, I have been told that this investigation may include an investigative consumer report, including information regarding my character, general reputation, personal characteristics, and mode of living. I agree to furnish such additional information and complete such examinations as may be required to complete my lease file. I also understand that misrepresentation or omission of information or facts may result in termination of lease. If a lease is signed, I agree to abide by all the rules and policies of the lease. 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.

Applicants Signature: Date:

Acknowledgement


MOTOR CARRIER INSTRUCTIONS: The requirements in Part 383 apply to every driver who operates in intrastate, interstate, or foreign commerce and operates a vehicle weighing 26,001 pounds or more, can transport more than 15 people, or transports hazardous materials that require placarding.

The requirements in Part 391 apply to every driver who operates in interstate commerce and operates a vehicle weighing 10,001 pounds or more, can transport more than 15 people, or transports hazardous materials that require placarding.

DRIVER REQUIREMENTS: Parts 383 and 391 of the Federal Motor Carrier Safety regulations contain some requirements that you as a driver must comply with. These requirements are in effect as of July 1, 1987. They are as follows:

1. POSSESS ONLY ONE LICENSE: You, as a commercial vehicle driver, may not possess more than one motor vehicle operator’s license.

If you have more than one license, keep the license from your state of residence and return the additional licenses to the states that issued them. DESTROYING a license does not close the record in the state that issued it; you must notify the state. If a multiple license has been lost, stolen, or destroyed, close your record by notifying the state of issuance that you no longer want to be licensed by that state.

2. NOTIFICATION OF LICENSE SUSPENSION, REVOCATION OR CANCELLATION: Sections 392.42 and 383.33 of the Federal Motor Carrier Safety Regulations require that you notify your employer the NEXT BUSINESS DAY of any revocation or suspension of your driver’s license. In addition, Section 383.31 requires that any time you violate a state or local traffic law (other than parking), you must report it within 30 days to 1) your employing motor carrier, and 2) the state that issued your license (If the violation occurs in a state other than the one which issued your license). The notification to both the employer and state must be in writing.

The following license is the only one I will possess:

Driver’s License No. State: Exp. Date:

DRIVER CERTIFICATION: I certify that I have read and understood the above requirements.

Print Applicants Name: Date:

Signature:

Certification of Compliance with Driver License Requirements

INSTRUCTIONS: When employed by a motor carrier, a driver must report to the carrier all on-duty time including time working for other employers. The definition of on-duty time found in Section 395.2 paragraphs (8) and (9) of the Federal Motor Carrier Safety Regulations includes time performing any other work in the capacity of, or in the employ or service of, a common, contract or private motor carrier, also performing any compensated work for any non-motor carrier entity.

Are you currently working for another employer? YES NO

At this time do you intend to work for another employer while still employed by this company? YES NO

I hereby certify that the information given above is true and I understand that once I become employed with this company, if I begin working for any additional employees) for compensation that I must inform this company immediately of such employment activity.


Driver Certification For Other Compensated Work

Driver License Requirements


MOTOR CARRIER INSTRUCTIONS: Each motor carrier shall at least once every 12 months, require each driver it employs to prepare and furnish it with a list of all violations of motor vehicle traffic laws and ordinances (other than violations involving only parking) of which the driver has been convicted, or on account of which he/she has forfeited bond or collateral during the preceding 12 months (Section 391.27). Drivers who have provided information required by Section 383.31 need not repeat that information on this form.

DRIVER REQUIREMENTS: Each driver shall furnish the list as required by the motor carrier above. If the driver has not been convicted of, or forfeited bond or collateral on account of any violation which must be listed, he/she shall so certify (Section 391.27).

COMPLETED BY DRIVER – CERTIFICATION OF VIOLATIONS

COMPLETED BY MOTOR CARRIER – ANNUAL REVIEW OF DRIVING RECORD

PRINTED NAME SOCIAL SECURITY NUMBER DATE OF EMPLOYMENT

HOME TERMINAL (CITY & STATE) DRIVER’S LICENSE # STATE EXP. DATE

I certify that the following is a true and complete list of traffic violations required to be listed (other than those I have provided under Part 383) for which I have been convicted or forfeited bond or collateral during the past 12 months.

(If you have had no violations, check the following box: (none)

DATE OFFENSE LOCATION TYPE OF VEHICLE OPERATED

If no violations are listed above, I certify that I have not been convicted or forfeited bond or collateral on account of any violation (other than those I have provided under Part 383) required to be listed during the past 12 months.

Date of Certification: Applicants Signature:

MOTOR CARRIER INSTRUCTIONS: Review the Certification of Violations listed above and other information described in Section 391.25 of the Federal Motor Carrier Safety Regulations. Complete the information requested below.I have hereby reviewed the driving record of the above named driver in accordance with Section 391.25 and find that he/she (check one):

Meets minimum requirements for safe driving Date of Certification:

Action taken with driver: Date of Certification:

Reviewed by:

Signature: Date:

Printed Name: Title:

MEADOW LARK TRANSPORT 220 Forlines Road Winterville, NC 28590

Certification of Violations/Annual Review of Driving Record

Annual Review


Return Fax #

I, , hereby authorize you to release all records of employment, including assessments of my job performance, ability, fitness (including dates of any and all alcohol or drug tests, those confirmed results, and/or my refusal to any alcohol or drug tests) to MEADOW LARK TRANSPORT, INC. (or their authorized agents) which may request such information in connection with my application for employment with said company. I hereby release this company from any and all liability of any type as a result of providing the following information to the below mentioned person and/or company.

NOTIFICATION OF DUE PROCESS RIGHTS – Please be advised the applicant has the right to review, request correction, or refute any information provided by previous employers. To do this, applicant must submit a written request at any time from the date of the application up to 30 days after beginning employment/lease or being denied employment/lease. This information shall be provided within five (5) business days after receiving written request.


*** REQUESTOR/PREVIOUS EMPLOYER USE ONLY ***

First Request: Second Request: Third Request:To: FAX #: PHONE #:

This person below has applied to lease to Meadow Lark Transport, Inc. as an Owner Operator in a safety-sensitive position. Your firm is listed by the applicant as a past employer. Please note the applicant’s waiver above, all liability of you and your company has been released by the applicant. If we do not receive the requested material, we will advise the Department of Transportation in your area of your failure to comply with these regulations.

From: Title: Safety Associate / Safety DepartmentCompany: Meadow Lark Transport, Inc. Address: 935 Lake Elmo Drive, Billings, MT 59105Phone: #: Fax Number:

Name of Applicant: Social Security Number:Dates of Employment - From: To: Yes NoIf no, Please explain:

If employed as a driver please answer the following:

Company driver Owner Operator Type of Trailer: Other Equip:Commodities Transported: General area of Operation:Accidents: Dates: Prev/Non Prev: Brief Description:

Citations:

Additional comments: (Any problems with customer relations, Supervisors, or abuse of equipment):

Why did this person leave your company?Would you re-employ this person? Yes No

THIS SECTION MUST BE COMPLETED BY PREVIOUS EMPLOYERDRUG/ALCOHOL TEST(S): (Previous two years) Drug AlcoholDate(s) of test(s) resulting in confirmed Positive result: (Alcohol tests with result of 0.04 alcohol concentration or greater)

Applicant refused to submit to testing:Any rehab completion under direction of SAP/MRO:Name: Title: Date:Company:

Previous Employment Request/Consent Form

Confidential


1. In connection with your application for employment with Meadow Lark Transport (“Prospective Employer”), 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 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.

The Prospective Employer cannot obtain background reports from FMCSA unless you consent in writing.

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

2. I authorize Meadow Lark Transport (“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 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 the Prospective Employer to make a determination regarding my suitability as an employee.

3. 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 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 Prospective Employer and I understand that if I sign this consent form, 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.

Print Applicant Name: Social Security #:

Date of Birth: Applicant Signature: Date:

Driver’s License Number: State of Issue Exp. Date:

Regarding Background Reports from the PSP Online Service

Important Notice


I understand that, as required by the Federal Motor Carrier Safety Regulations 49 CFR Part 382 and company policy, all prospective drivers must submit to a controlled substances test involving collection of a urine sample that will be tested for the following controlled substances: marijuana, cocaine, opiates, amphetamines and phencyclidine (PCP).

I understand that, if I test positive for use of controlled substances, I am not medically qualified to operate a commercial motor vehicle. I also understand I will be given a reasonable opportunity to confer with the company’s medical review officer before any positive drug test result is reported to the company.

The results of the drug tests will be maintained by the medical review officer of the company, who will report to the company whether the test result was negative or positive. The results of any tests will not be released to any additional parties except as provided in § 40.37 without my written authorization.

I hereby agree to submit to a urine drug test.

Date: Printed Name:

Applicant’s Signature:

Release & documentation of pre-employment testing informationTo be completed by driver/applicant

YES NO During the past (2) two years, have you tested positive on a pre-employment drug or alcohol test administered by an employer to which you applied for, but did not obtain, safety sensitive transportation work covered by the Department of Transportation (DOT) drug and alcohol testing rules?

YES NO During the past (2) two years, have you refused to test on a pre-employment drug or alcohol test administered by an employer to which you applied for, but did not obtain, safety-sensitive transportation work covered by the Department of Transportation (DOT) drug and alcohol testing rules?

If you answered yes to either of the questions above, please provide documentation of your successful completion of the return-to-duty process.

Printed Name: Social Security #:

Signature: Date:

Record-keeping requirements:

If driver / applicant answer is “yes” to either question — 5 yearsIf driver / applicant answer is “no” to both questions — keep for length of driver’s employmentThis form may be used to fulfill the requirement of Part 40.25(j). As an employer you must ask the driver whether he/she has tested positive, or refused to test, on any pre-employment drug or alcohol test administered by an employer to which the driver applied for, but did not obtain, safety-sensitive transportation work covered by DOT agency drug and alcohol testing rules during the past 2 years.

Drug Testing Notification And Consent

Pre- Employment


PART I - DISCLOSURE AND AUTHORIZATION FOR RELEASE OF INFORMATION FOR EMPLOYMENT PURPOSES - 49 CFR PART 391.23. DOT DRUG AND ALCOHOL TESTING

In accordance with DOT Regulation 49 CFR Part 391.23, I hereby authorize release of my DOT-regulated drug and alcohol testing records by the DOT-regulated employer(s) listed below to USIS for the purpose of USIS transmitting such records to the USIS customer listed above. I understand that information/documents released pursuant to this Part I is limited to the following DOT-regulated testing items, including pre-employment testing results, occurring during the previous three (3) years: (i) alcohol tests with a result of 0.04 or higher; (ii) verified positive drug tests; (iii) refusals to be tested (including adulterated and/or substituted tests); (iv) other violations of DOT drug and alcohol testing regulations (i.e., violations of 49 CFR 382 Subpart B); (v) information obtained from previous employers of a drug and alcohol rule violation; and (vi) any documentation of completion of the return-to-duty process following a rule violation.

If any company listed below furnishes USIS with information concerning items (i) through (vi) above, I also au-thorize such company to furnish the following information to USIS, if applicable: (i) dates of my negative drug and/or alcohol tests and/or tests with results below 0.04 during the previous three (3) years; and (ii) the name and phone number of any substance abuse professional who evaluated me during the previous three (3) years.

List all DOT-regulated employers you have applied with and/or worked for in a safety-sensitive function during the previous three (3) years. If necessary, attach additional pages, including the date, your name, social securi-ty number and signature.

Previous DOT-Regulated Employer City State Phone Number

By signing below, I certify that: (i) all information provided herein is complete and accurate; (ii) I have read and fully understand this Part 1 disclosure and authorization for release; (iii) prior to signing I was given an oppor-tunity to ask questions and to have those questions answered to my satisfaction; (iv) I execute this authoriza-tion voluntarily and with the knowledge that the information obtained pursuant to this authorization could affect my eligibility for employment, promotion, retention or other lawful purpose; (v) I understand I may review this document with legal counsel prior to signing; and (vi) facsimile or photographic copies of this authorization are as valid as an original.


Applicant Signature: Date:

HireRight Company Name: Meadow Lark Transport, Inc.DAC Trucking Company Contact Name:Send to Fax # (800) 267-4093 (Manual Service) Fax #:Send to Fax # (800) 257-8069 (Database Retrieval) Hireright Customer: 19678

DOT D/A Disclosure and Authorization

Trucking Industry


PART II - In connection with your employment or application for employment (including contract for services) through Meadow Lark Transport, Inc., consumer reports (Investigative Consumer Reports in California) may be requested from HireRight (formerly USIS Commercial Services). These reports may include the following types of information: names and dates of previous employers, reasons for termination of employment, work experience, accidents, academic history, professional credentials and drug/alcohol use. Such reports may contain public record information concerning your driving record, workers compensation claims, credit, bankruptcy proceedings, criminal records, etc. from federal, state and other agencies that maintain such records; as well as information from HireRight concerning previous driving record requests made by others from such state agencies and state provided driving records.

We also will obtain driving/accident and safety inspection history records maintained by the Federal Motor Carrier Safety Administration (“FMCSA”).

You have the right to make a request to HireRight, upon proper identification, to request the nature and substance of all information in its files on you at the time of your request, including the explaining of any coded information, the sources of information and the recipients of any reports on you that HireRight has previously furnished within the past two year period preceding your request (3 years in California). HireRight may be contacted by mail at P.O. Box 33181, Tulsa, OK 74153 or by telephone at 800-381-0645. You may also bring a third party with you to view the information at the HireRight offices if this person provides proper identification.

I AUTHORIZE, WITHOUT RESERVATION, HIRERIGHT, FMCSA AND ANY OTHER PARTY OR AGENCY CONTACTED BY HIRERIGHT TO FURNISH THE ABOVE MENTIONED INFORMATION. THIS AUTHORIZATION DOES NOT APPLY TO DRUG AND ALCOHOL INFORMATION CONTAINED UNDER PART I.

I hereby consent to your obtaining the above information from HireRight, and I agree that such information which HireRight has or obtains in my employment history (not DOT drug and alcohol information without a specific consent by me) with you if l am hired, will be supplied by HireRight to other companies which subscribe to HireRight. I hereby authorize procurement of consumer reports as set forth above.

If hired or contracted, this authorization for reports covered by this release only shall remain on file and shall serve as an ongoing authorization for you to procure consumer reports at any time during my employment or contract period.

I consent to you obtaining the above information from FMCSA. I understand that the FMCSA maintains sole control over that data and you cannot change or alter such information. If I dispute any information maintained by FMCSA, I must personally contact the FMCSA by accessing the DataQs System at: https://dataqs.fmcsa.dot.gov.


Date of Birth: Applicant Signature: Date:

Driver’s License Number: State of Issue Exp. Date:

Disclosure and Release

Authorization to Release Records

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