COMMERCIAL DRIVER - APPLICATION FORM

Personal Information: **Confidential** (when completed) This data is gathered under the provisions of the Privacy Act for protection.

Do you have a FAST CARD

Education : List from present to past.

REFERENCE:

As a motor carrier, it is imperative to adhere to FMCSA Part 391 (in part), which outlines that drivers of commercial motor vehicles must meet specific qualifications. Additionally, this section delineates the obligations that motor carriers must fulfill to ensure driver qualification. In summary, prospective drivers must meet the following requirements:

If yes, please provide the following:

Are you newly employed? Yes   No  

Date/contact for last employer

Are there any physical conditions, which may limit your ability to perform the job applied for? Yes   No  

Can you provide proof of physical status within the last six months? Yes   No  

How much time was lost from work in the past three (3) years for illness?

Please provide details of any motor vehicle accidents you have been involved in over the past three years, whether minor or major, in the space provided below:

Please list any motor violations of motor vehicle laws or ordinances (excluding parking violations)
for which you were convicted, forfeited bond, or collateral within the past 3 years.

If you have ever experienced denial, revocation, or suspension of any license, permit, or privilege to operate
a motor vehicle, please provide a detailed statement outlining the facts and circumstances
surrounding the incident.

I, hereby certify that above information provided by me is accurate and up to date

By signing below, I acknowledge that I have read, understood, and verified that all information provided is true.

Per Federal Motor Carrier Safety Regulations (section 395.8 (j) (2)), motor carriers must obtain a signed statement from drivers when using them for the first time or intermittently. This statement should include the driver's total time on-duty during the immediately preceding seven days and the time at which the driver was last relieved from duty before commencing work for the carrier. Additionally, please note that hours for any compensated work during the preceding fourteen days, including work for non-motor carrier entities, must be recorded on this form.

For office use only

EMPLOYMENT HISTORY

All driver applicants to drive in interstate commerce must provide the following information on all employers during the preceding 10 years. List complete mailing address, street number, city, state, zip/Postal code, and Phone number.

(Note: List employers in reverse order starting with the most recent.)

Were you subject to the Federal Motor Carrier Safety Regulations while employed by the previous employer? Yes   No  

Was the previous job position designated as a safety sensitive function in any DOT regulated mode subject to alcohol and controlled substances testing requirments as required by 49 CFR Part 40?
Yes   No  

Were you subject to the Federal Motor Carrier Safety Regulations while employed by the previous employer? Yes   No  

Was the previous job position designated as a safety sensitive function in any DOT regulated mode subject to alcohol and controlled substances testing requirments as required by 49 CFR Part 40?
Yes   No  

Were you subject to the Federal Motor Carrier Safety Regulations while employed by the previous employer? Yes   No  

Was the previous job position designated as a safety sensitive function in any DOT regulated mode subject to alcohol and controlled substances testing requirments as required by 49 CFR Part 40?
Yes   No  

TO BE READ AND SIGNED BY APPLICANT

• I authorize you to conduct necessary investigations and inquiries into my personal, employment, financial, or medical history, as required for employment decisions. Please note that inquiries regarding medical history will typically occur only after a conditional offer of employment has been extended. I hereby release employers, schools, health care providers, and other relevant entities from any liability in responding to inquiries and releasing information related to my application.
• In the event of employment, I understand that providing false or misleading information during the application process or interviews may result in termination. I also acknowledge my obligation to comply with all company rules and regulations.
• I understand that information provided about current and/or previous employers may be utilized, and these employer(s) will be contacted, to investigate my safety performance history as mandated by 49 CFR 391.23(d) and (e). I acknowledge that I have the right to:
• Review information provided by current/previous employers.
• Request corrections to any errors in the information provided by previous employers, and for them to resend the corrected information to the prospective employer.
• Attach a rebuttal statement to any alleged erroneous information if agreement cannot be reached between the previous employer(s) and myself regarding its accuracy.

Medical Fitness Policy

FMCSA: It is the policy of Bison Transport, referred to hereafter as the "Company," to operate in compliance with Federal Motor Carrier Safety regulations, specifically Part 391.43.

PROCEDURE:

Any employee candidate seeking a position with the company that involves driving a commercial vehicle on public roadways in the United States must adhere to the physical requirements outlined in FMCSA Regulations.

On March 30, 1999, Transport Canada and the U.S. Federal Highway Administration (FHWA) entered into a reciprocal agreement regarding the physical requirements for Canadian drivers of commercial vehicles in the U.S., as outlined in Federal Motor Carrier Safety regulations, Part 391.43, and vice versa. This agreement eliminates the need for Canadian drivers to carry a copy of a medical examiner's certificate, provided they possess a valid driver's license issued by the province of Ontario, which is deemed proof of physical qualification. However, FHWA will not recognize an Ontario license if the driver has certain medical conditions that would prohibit driving in the U.S.

POLICY:

• All drivers must sign Medical Declaration Forms upon hiring.
• Drivers must submit medical forms signed by a physician during regular medical checkups as per the Ministry of Transportation Commercial Vehicle Driving requirements.
• Drivers must promptly notify the company of any changes in health conditions stated in the medical declaration form.
• The company will securely maintain records of Medical Declaration Forms and subsequent signed medical reports.

Effective Date:

The Driver Medical Fitness Policy shall be effective.  

MEDICAL DECLARATION:

On March 30, 1999, the United States Federal Motor Carrier Safety Regulation medical requirements for Canadian drivers of Commercial Motor Vehicles operating in the United States were revised. I acknowledge that there is no requirement for a completed United States medical fitness report. This revision requires that a Canadian driver must comply with the medical requirements of the province in which their Commercial Driver’s License is issued, and that a medical fitness report is completed as required by the license issuing province.

I, , certify that under the new revisions of the medical requirements to operate a commercial motor vehicle in the United States, I am not impaired to operate a Commercial Motor Vehicle by any of the following:

• A) I have no established medical history or clinical diagnosis of diabetes mellitus currently requiring insulin for control (administered by injection).
• B) I have no established medical history or clinical diagnosis of epilepsy.
• C) I do not have impaired hearing, first perceives a forced whispered voice in the better ear at no less than 5 feet with or without the use of a hearing aid or, if tested by use of an audiometric device, does not have an average hearing loss in the better ear greater than 40 decibels at 500 Hz., 1,000Hz, and 2,000Hz with or without a hearing aid when the audiometric device is calibrated to American National Standard (formerly ASA Standard) Z24.s – 1951.
• D) I do not have high blood pressure exceeding 160/90.
• E) I also agree to inform the company should my medical status change, and if any of the above impairments are subsequently diagnosed to affect my fitness to operate a Commercial Motor Vehicle in the United States.

I hereby authorize you to release the following information to Bison Transport for the purpose of investigation as required by Section 391.23 of the Federal Motor Carrier Safety Regulations. You are released from all liability, which may result from furnishing such informational.

FORM 413 / 301
REQUEST FOR DRUG AND ALCOHOL TESTING INFORMATION
FROM PREVIOUS EMPLOYERS in accordance with 49 CFR 382.413 and 49 CFR 40.25 AND FOR PRE-EMPLOYMENT TEST EXEMPTION in accordance with 49 CFR 382.301(b)

PURPOSE OF THIS FORM: (A) Under 49 CFR 382.413 which refers to 49 CFR 40.25 of the DOT regulations, previous employers MUST provide information regarding any violations of the regulations, specifically, any alcohol tests with a result of 0.04 or greater, any verified positive drug tests and any refusals to be tested (including verified adulterated or substituted drug test results), as well as information on whether the employee completed the required assessment and requalification provisions under the regulations in accordance with 49 CFR Part 40 Subpart O. (B) (I) Under 49 CFR 382.301(b) a prospective employer is not required to administer a preemployment drug test on hiring a driver if he/she can verify the prospective driver’s previous participation in a compliant testing program [382.301(c)(1)]. An employer can exercise this exemption if he contacts the testing program and obtains the information below. (II) Under 49 CFR 382.301(c)(2) an employer who hires a temporary or contract driver participating in a testing program administered by another entity must verify the driver’s participation in a compliant testing program. If a driver is used periodically, the information must be updated every 6 months

The person applied to our company for a safety-sensitive position as outlined in 49 CFR 382.107. In compliance with DOT regulations 49 CFR 382.413, 49 CFR 40.25 and 382.301, we are hereby requesting information regarding this individual’s involvement with your company’s drug and alcohol testing program. Consent for the release of this information follow

APPLICANT/DRIVER CONSENT