Docstoc

EQUIPMENT _ DRIVER QUALIFICATION FORM

Document Sample
EQUIPMENT _ DRIVER QUALIFICATION FORM Powered By Docstoc
					                                                    Meadow Lark Transport
                                             935 Lake Elmo Drive, Billings, MT 59105
                                            Phone: 866-736-5233 Fax: 406-256-0343


                                                                      APPLICATION
Name                                                                                            Phone: (                 )
                    First                 Middle                     Last
                                                                                                Cellphone: (______) ______________
Social Security #: _______________________

Date of Birth: __________________________

Current Address
                                         Street                                                                   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.


                    Street                                                                                        City                 State     Zip Code


                    Street                                                                                        City                 State     Zip Code




IN CASE OF EMERGENCY NOTIFY:                                                                            Phone: (             )         _______
Address:                                                                                                      Relationship:
                    Street                                City                     State     Zip Code




Position applying for? Owner/Operator                            Driver      (Circle One)
Who referred you?                        ___________                               _____________________________________
Have you worked for this company before? Yes or No                                     If yes, dates of service ___________
Names of any relatives employed by this company


Are you currently employed? Yes or No If 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?

                                                                        GENERAL
Have you ever been convicted of a felony? Yes or No (Circle one)
If yes, please explain fully on a separate sheet of paper. Conviction of a crime 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 or No (circle one)
B. Has any license, permit or privilege ever been suspended or revoked?                                                          Yes or No (circle one)
C. Have you ever been disqualified for violations of the Federal Motor Carrier Safety Regulations? Yes or No (circle one)
    If you answered “yes” to A, B, or C, attach a statement giving details.

                                                                                                                         Driver Application-Rev. 2/18/08 Page 1 of 10
                                                        EMPLOYMENT RECORD
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 proceeding 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.

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

Current Employer:                                                                             Supervisors Name:
Address:                                                                                      Phone (         )
Position Held:                                    From:                  To:                  Reason for Leaving:
                                                          (month/year)         (month/year)
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                    ________ No
Trailer type pulled: Flatbed Stepdeck RGN DD Van                          Reefer (please circle) Other:


Past Employer:                                                                                Supervisors Name:
Address:                                                                                      Phone (         )
Position Held:                                    From:                  To:                  Reason for Leaving:
                                                          (month/year)         (month/year)
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                    ________ No
Trailer type pulled: Flatbed Stepdeck RGN DD Van Reefer (please circle) Other:


Past Employer:                                                                                Supervisors Name:
Address:                                                                                      Phone (         )
Position Held:                                    From:                  To:                  Reason for Leaving:
                                                          (month/year)         (month/year)
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                    ________ No
Trailer type pulled: Flatbed Stepdeck RGN DD Van Reefer (please circle) Other:


Past Employer:                                                                                Supervisors Name:
Address:                                                                                      Phone (         )
Position Held:                                    From:                  To:                  Reason for Leaving:
                                                          (month/year)         (month/year)
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                    ________ No
Trailer type pulled: Flatbed Stepdeck RGN DD Van Reefer (please circle) Other:


                                                                                                                     Driver Application-Rev. 2/18/08 Page 2 of 10
Past Employer:                                                                     Supervisors Name:
Address:                                                                           Phone (       )
Position Held:                         From:                  To:                  Reason for Leaving:
                                               (month/year)         (month/year)
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        ________ No
Trailer type pulled: Flatbed Stepdeck RGN DD Van Reefer (please circle) Other:

Past Employer:                                                                     Supervisors Name:
Address:                                                                           Phone (       )
Position Held:                         From:                  To:                  Reason for Leaving:
                                               (month/year)         (month/year)
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        ________ No
Trailer type pulled: Flatbed Stepdeck RGN DD Van Reefer (please circle) Other:


Past Employer:                                                                     Supervisors Name:
Address:                                                                           Phone (       )
Position Held:                         From:                  To:                  Reason for Leaving:
                                               (month/year)         (month/year)
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        ________ No
Trailer type pulled: Flatbed Stepdeck RGN DD Van Reefer (please circle) Other:

Past Employer:                                                                     Supervisors Name:
Address:                                                                           Phone (       )
Position Held:                         From:                  To:                  Reason for Leaving:
                                               (month/year)         (month/year)
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        ________ No
Trailer type pulled: Flatbed Stepdeck RGN DD Van Reefer (please circle) Other:

Past Employer:                                                                     Supervisors Name:
Address:                                                                           Phone (       )
Position Held:                         From:                  To:                  Reason for Leaving:
                                               (month/year)         (month/year)
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        ________ No
Trailer type pulled: Flatbed Stepdeck RGN DD Van Reefer (please circle) Other:


                                                                                                         Driver Application-Rev. 2/18/08 Page 3 of 10
  Drivers License                  State                    License No.                   Class       Endorsement(s)                  Exp
  held in the past 3                                                                                                                  Date
  years must be
  shown




Accident Review for past 3 years (Attach separate sheet of paper if more space is needed)
                          Nature of accident
 Dates           (Head-On, Rear-End, Overturn, etc.)   Fatalities              Injuries
 Last Accident
 Next Previous
 Next Previous



Traffic convictions and Forfeitures for the past 3 years other than parking violations
             Location                   Date                    Charge                 Penalty




                                      APPLICANT MUST READ AND SIGN

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.


Date                                                      Applicants Signature



                                     FOR OFFICE USE – DO NOT WRITE IN THIS SPACE
Applicant Hired? YES or NO Date Employed                             (If not hired, summary report of reasons should be placed in file)

                                               TERMINATION OF EMPLOYMENT
Date Terminated:                      Dismissed:                      Voluntarily Quit:                       Other: ______________

                                                                                                         Driver Application-Rev. 2/18/08 Page 4 of 10
To: Drug Records Dept / 800-322-5298                        From:

TRUCKING INDSUTRY:                                                                     USIS Customer:
DOT D/A Disclosure and Authorization
                                                              Company Name:_Meadow Lark Transport
                                                              Company Contact Name: Stacey Collett
                                                              Fax #: (406) 256-0343
                                                              USIS Customer #: 19678            Sub-account:__________
Send to Fax # (800) 267-4093 (Manual Service)
Send to Fax # (800) 257-8069 (Database Retrieval)

         PART 1 – 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 authorize 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 security 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 opportunity to ask questions and to have
those questions answered to my satisfaction; (iv) I execute this authorization 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.

Print Applicant Name:________________________________________ Social Security #:_________________________

Applicant Signature:______________________________________________ Date:___________________________
DOT Drug/Alcohol Disclosure/Authorization                                                                                      02/06
Trucking Industry – Employment Purpose
                                                             Page 1 of 2

                                                                                                  Driver Application-Rev. 2/18/08 Page 5 of 10
             PART II – CONSUMER REPORT AND INVESTIGATIVE CONSUMER REPORT DISCLOSURE
                                    (FOR EMPLOYMENT PURPOSES)

In connection with your employment or application for employment (including contract for services) and in accordance with
applicable laws, USIS may obtain or assemble consumer reports and/or investigative consumer reports (collectively, “Reports”)
which may include information about you related to: previous employment (including employers, dates of employment, salary
information, reasons for termination, etc.), accident history, academic history, verification of references and other information
supplied by applicant, professional credentials, drug/alcohol use in violation of law and/or company policy, driving record,
workers’ compensation claims, credit history, creditworthiness, credit capacity, bankruptcy filings, criminal history records,
information about your character, general reputation, personal characteristics and mode of living (collectively “Information”).
Information may be obtained from government agencies, educational institutions, USIS clients, personal references, personal
interviews and other information suppliers (collectively, “Suppliers”).

Upon providing proper identification and complying with any applicable legal requirements, you have the right to request the
nature and substance of all Information in USIS’s files pertaining to you at the time of your request, including but not limited to: (i)
whether any Reports have been provided by USIS to other parties; (ii) identification of any Suppliers utilized by USIS in
compiling such Reports: and (iii) identification of any recipients of Reports furnished by USIS within the two (2) year period
preceding your request. USIS may be contacted by mail at PO Box 33181, Tulsa, OK, 74153, or by phone at (800) 381-0645.


            Check this box if you are applying for employment in California and/or you are a California resident and, in either case, you
wish to receive a copy of your credit report or investigative consumer report if one is obtained or assembled by USIS. Pursuant to
the California Civil Code, you may view the file maintained on you by USIS during normal business hours. You may also obtain a copy
of this file by submitting proper identification and paying applicable costs for such file, if required by law, by contacting USIS in person or
by mail. USIS is required to have personnel available to explain your file to you and 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.

         Check this box if you are applying for employment in Oklahoma and / or you are an Oklahoma resident and, in either case, you
wish to receive a copy of your consumer report if one is obtained or assembled by USIS.

         Check this box if you are applying for employment in Minnesota and / or you are a Minnesota resident and, in either case, you
wish to receive a copy of your consumer report if one is obtained or assembled by USIS.

         PART II – AUTHORIZATION FOR RELEASE OF INFORMATION (FOR EMPLOYMENT PURPOSES)
I hereby authorize USIS to receive information and disclose such information to its customers for the purpose of making a determination as to
my eligibility for employment, promotion, retention or other lawful purpose. If hired or contracted, I authorize USIS and the USIS customer
named above (“Customer”) to retain this document on file to act as ongoing authorization for the procurement and possession of Reports at
any time during my employment or contract period. I fully release USIS and Suppliers from all claims of damages related to the investigation of
my background and provision of information as set forth in this disclosure and authorization. I agree that Information in USIS’s possession and
my employment history with customer if I am hired, may be supplied by USIS to other USIS customers for legally permissible purposes;
provided, such Information will not include the Drug and Alcohol information set forth in Part 1 above, unless I have given a separate specific
consent for USIS to share such Information.

By signing below, I certify that: (i) all information provided herein is complete and accurate; (ii) I have read and fully understand this Part II
disclosure and authorization for release; (iii) prior to signing I was given an opportunity to ask questions and to have those questions answered
to my satisfaction; (iv) I execute this authorization 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; (vi) I authorize USIS and any person or entity contacted by USIS to furnish the above-mentioned
Information; and (vii) facsimile or photographic copies of this authorization are as valid as an original.

         NOTE – THIS AUTHORIZATION DOES NOT APPLY TO DRUG & ALCOHOL INFO. ADDRESSED IN PART 1

Print Applicant Name:__________________________________________ Social Security #:________________________________

Applicant Signature:________________________________________________                            Date:____________________________


DOT Drug/Alcohol Disclosure Authorization                       Page 2 of 2                                                                 2/06
Trucking Industry – Employment Purpose




                                                                                                              Driver Application-Rev. 2/18/08 Page 6 of 10
                                                   CONFIDENTIAL
                                   PREVIOUS EMPLOYMENT REQUEST/CONSENT FORM
                                              Return Fax # 406-256-0343

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 (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 anytime 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.

_________________________________________________________________                                            _____________________
(Applicants Signature)                                                                                              (Date)

                                      *** REQUESTOR/PREVIOUS EMPLOYER USE ONLY ***
First Request:                                Second Request:                               Third Request:

TO:                                                                      FAX NUMBER:

                                                                         PHONE NUMBER:

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 Department
Company: Meadow Lark Transport, Inc.                                    Address: 935 Lake Elmo Drive, Billings, MT 59105
Phone# 406-256-0063 / 800-736-5233                                      Fax Number: 406-256-0343

Name of Applicant                                                       Social Security Number
Dates of Employment From                                       to                                  Yes or No (Please circle one)
If 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 or No

                            THIS SECTION MUST BE COMPLETED BY PREVIOUS EMPLOYER
DRUG/ALCOHOL TEST(S): (Previous two years)                                       Drug                                  Alcohol
Date(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:

                                                                                                          Driver Application-Rev. 2/18/08 Page 7 of 10
                                             Motor Vehicle Driver’s
                                        CERTIFICATION OF COMPLIANCE
                                     WITH DRIVER LICENSE REQUIREMENTS
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.

Applicants Name: _______________________________________ Date: _____________________
                   (please print)
Signature: ________________________________________________________________________




                        DRIVER CERTIFICATION FOR OTHER COMPENSATED WORK
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 employer(s) for compensation that I must inform
this company immediately of such employment activity.


Applicants Signature                                             Date
                                                                                            Driver Application-Rev. 2/18/08 Page 8 of 10
                                               MOTOR VEHICLE DRIVER’S
                              Certification of Violations/Annual Review of Driving Record
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

 NAME OF DRIVER: (PRINT)                                                SOCIAL SECURITY NUMBER                          DATE OF EMPLOYMENT


 HOME TERMINAL (CITY AND STATE)                                         DRIVER’S LICENSE NUMBER STATE                   EXPIRATION 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 __________________________________________




             COMPLETED BY MOTOR CARRIER – ANNUAL REVIEW OF DRIVING RECORD
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                    Is disqualified to drive a motor vehicle pursuant to Section 391.15

      Does not adequately meet satisfactory safe driving performance

Action taken with driver: _____________________________________________________________________________________

Reviewed by: ___________________________________________________                        ______________________________________
              Signature                                                                   Date
           ___________________________________________________                          ______________________________________
              Printed Name                                                                Title

            MEADOW LARK TRANSPORT                                                  P.O. BOX 50575, BILLINGS, MT 59105
      MAINTAIN THIS DOCUMENT IN THE DRIVER’S QUALIFICATION FILE. THIS DOCUMENT MAY BE PURGED AFTER 3 YEARS FROM DATE OF EXECUTION.



                                                                                                             Driver Application-Rev. 2/18/08 Page 9 of 10
                                            PRE-EMPLOYMENT DRUG TESTING
                                              NOTIFICATION AND CONSENT
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 S 40.37 without my written authorization.
I hereby agree to submit to a urine drug test.

Date: ___________               Name of Applicant:
                                                            (please print)

Applicant’s signature




                     Release & documentation of pre-employment testing information
                                  To be completed by driver/applicant.

    YES        NO (check one)                    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 (check one)                    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.
______________________________________________________________________________

Name of Applicant:__________________________________ Social Security #:____________________
                           (please print)

Applicants Signature:________________________________ Date: ______________________

             Record-keeping requirements:

             If driver / applicant answers “yes” to either question – 5 years
             If driver / applicant answers “no” to both questions – keep for length of driver’s employment
This 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.
                                                                                                        Driver Application-Rev. 2/18/08 Page 10 of 10

				
DOCUMENT INFO