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Owner Operator Driving and Equipment Lease Agreement document sample
Owner Operator Driving and Equipment Lease Agreement document sample
OWNER OPERATOR VITAL INFORMATION SHEET Owner Operator Vital information Sheet Applicant Name_________________________________________ Date of Application______________________________________ Continuum Transportation Services, LTD. 4500 Lee Rd, Suite 138, Cleveland, Oh 44128 Qualified applicants are considered for driving positions as owner operators and drivers for owner operators. I understand that the position is as an independent contractor, not an employee of Continuum Transportation Services, LTD. In compliance with applicable law and regulation, qualified applicants are considered without regard to race, color, religion, sex, national origin, age, marital status, veteran status, non job related disability or other protected group status. To Be Read and Signed by Applicant I authorize Continuum Transportation Services, LTD. And any of its employees, agents or contractors, to make such investigations and inquiring of my personal employment , financial or medical history, any related matters as may be necessary or required in determining whether to qualify me as a driver for Continuum transportation. I hereby release Continuum Transportation Services, LTD. As well as my current and former employers, schools (including technical schools and professional training schools), health care providers and any other persons from any and all liability arising out of or related to responding to inquiries from Continuum Transportation and releasing any information to Continuum Transportation in connection with my application. In the event that Continuum Transportation Services, LTD. qualifies me, I recognize and acknowledge that any false or misleading information I provide in this application may result in Continuum Transportation terminating my contract as an owner operator. I also recognize and acknowledge that I am required to abide by all provisions of the equipment lease agreement between Continuum Transportation and the owner of the vehicle, and my failure to abide by the provisions may result in termination of our business relationship. I understand that the information I provide in this application regarding current and/or previous employers may be used and those employer(s) will be contacted for the purpose, in part, of investigating my safety performance history as required by 49 CFR 391.23 (d) and (e). I understand that I have a right to (1) review information provided by the previous employers, (2) have errors in the information corrected by previous employers, (3) have the previous employer forward corrected information to the prospective employer and (4) have a rebuttal statement attached to the allegedly erroneous information if the previous employer and I cannot agree on the accuracy of the information. Driver Signature________________________________ For Continuum Transportation Services, LTD. use only ____ Applicant Accepted ____Applicant Rejected ____Owner Operator Start Date:_____/_______/_______ _____Driver Termination Date:____/_____/_____ Continuum Transportation Services, LTD. 4500 Lee Rd. Suite 138, Cleveland, Oh 44128 Applicant to Complete (Answer all questions, Please print) Position applied for_____________________________________________________________________ Last Name____________________________First_________________________Middle_____________ Social Security_________-__________-__________ List your Addresses of residency for the past 3 years Current Address Street____________________________________________City_________________________________ State____________Zip_______________Phone___________________How long?__________________ Previous Address Street____________________________________________City_________________________________ State____________Zip_______________Phone___________________How long?__________________ Street____________________________________________City_________________________________ State____________Zip_______________Phone___________________How long?__________________ Emergency Contact_____________________________________________________________________ Name________________________Relationship________________________Phone_________________ Do you have the legal right to work in the United States?______________________________________ Date of Birth_______/________/________ Can you provide proof of age_________________________ Have you worked for Continuum Before?______________ Where?_____________________________ Dates: From:__________ To:________Rate of Pay_________ Position___________________________ Reason for leaving______________________________________________________________________ Are you now employed?________ If not, how long since your last employment____________________ Who referred you?______________________ Rate of pay expected_____________________________ Have you ever been bonded?______________Name of bonding company________________________ Have you ever been convicted of a felony?__________________________________________________ (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) Is there any reason you might be unable to perform the functions of the job for which you have applied?______________ If yes, explain if you wish________________________________________________________________ Continuum Transportation Services, LTD. EMPLOYMENT HISTORY All driver applicants to drive interstate commerce must provide the following information on all employers during the preceding 10 years. List complete mailing address, street number, city, state, and zip code. (NOTE: List employers in reverse order starting with the most recent. Add another sheet if necessary.) 10 Year Employment History EMPLOYER DATE NAME FROM: TO: ADDRESS POSITION HELD CITY WAGE STATE ZIP REASON FOR LEAVING CONTACT PERSON PHONE NUMBER EMPLOYER DATE NAME FROM: TO: ADDRESS POSITION HELD CITY WAGE STATE ZIP REASON FOR LEAVING CONTACT PERSON PHONE NUMBER EMPLOYER DATE NAME FROM: TO: ADDRESS POSITION HELD CITY WAGE STATE ZIP REASON FOR LEAVING CONTACT PERSON PHONE NUMBER EMPLOYER DATE NAME FROM: TO: ADDRESS POSITION HELD CITY WAGE STATE ZIP REASON FOR LEAVING CONTACT PERSON PHONE NUMBER 10 Year Employment History (continued) EMPLOYER DATE NAME FROM: TO: ADDRESS POSITION HELD CITY WAGE STATE ZIP REASON FOR LEAVING CONTACT PERSON PHONE NUMBER EMPLOYER DATE NAME FROM: TO: ADDRESS POSITION HELD CITY WAGE STATE ZIP REASON FOR LEAVING CONTACT PERSON PHONE NUMBER EMPLOYER DATE NAME FROM: TO: ADDRESS POSITION HELD CITY WAGE STATE ZIP REASON FOR LEAVING CONTACT PERSON PHONE NUMBER EMPLOYER DATE NAME FROM: TO: ADDRESS POSITION HELD CITY WAGE STATE ZIP REASON FOR LEAVING CONTACT PERSON PHONE NUMBER EMPLOYER DATE NAME FROM: TO: ADDRESS POSITION HELD CITY WAGE STATE ZIP REASON FOR LEAVING CONTACT PERSON PHONE NUMBER ACCIDENT RECORD AND FORFEITURES FOR THE PAST 3 YEARS NATURE OF ACCIDENT(HEAD-ON, REAR- HAZ-MAT DATES END,ETC.) FATALITIES INJURIES SPILLS LAST PREVIOUS PREVIOUS TRAFFIC CONVICTIONS AND FORFEITURES FOR THE PAST 3 YEARS(OTHER THAN PARKING VIOLATIONS) IF NONE WRITE NONE DATE LOCATION CHARGE PENALTY (ATTACH SHEET IF MORE SPACE IS NEEDED) EXPERIENCE AND QUALIFICATION – DRIVER (LIST ALL LICENSES OR PERMITS HELD IN THE PAST 3 YEARS) STATE LICENSE NUMBER TYPE Expiration Date DRIVER LICENSES A. HAVE YOU EVER BEEN DENIED A LICENSE, PERMIT OR PRIVELEGE TO OPERATE A MOTOR VEHICLE? YES__________ NO___________ B. HAS ANY LICENSE, PERMIT OR PRIVILEGE EVER BEEN SUSPENDED OR REVOKED? YES__________ NO___________ If the answer to either A or B is Yes, give details_____________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ DRIVING EXPERIENCE APPROX# OF CLASS OF EQUIPMENT TYPE OF EQUIPMENT DATES MILES YES NO TO FROM STRAIGHT TRUCK VAN/CONTAINER/FLAT/DUMP TRACTOR & SEMI-TRAILER VAN/CONTAINER/FLAT/DUMP TRACTOR & TWO TRAILERS VAN/CONTAINER/FLAT/DUMP TRACTOR & THREE TRAILERS VAN/CONTAINER/FLAT/DUMP MOTORCOACH/SCHOOL BUS OTHER LIST STATES OPERATED IN FOR THE LAST 5 YEARS: _________________________________ ______________________________________________________________________________________ LIST SPECIAL COURSES OR TRAINING THAT WILL HELP YOU AS A DRIVER: ______________________________________________________________________________________ WHICH SAFE DRIVING AWARDS DO YOU HOLD AND FROM WHOM: ___________________ EXPERIENCE & QUALIFICATIONS – OTHER SHOW ANY TRUCKING, TRANSPORTATION OR OTHER EXPERIENCE THAT MAY HELP YOU WORK FOR THIS COMPANY ______________________________________________________________________________________ ______________________________________________________________________________________ LIST COURSES AND TRAINING OTHER THAN SHOWN ELSEWHERE IN THIS APPLICATION. _______________________________________________________________________ LIST SPECIAL EQUIPMENT OR TECHNICAL MATERIALS YOU CAN WORK WITH. ______ EDUCATION CIRCLE HIGHEST GRADE COMPLETED: 1 2 3 4 5 6 7 8 HIGH SCHOOL: 1 2 3 4 COLLEGE: 1 2 3 4 LAST SCHOOL ATTENDED (NAME)_______________________(CITY,STATE)_________________________ TO BE READ AND SIGNED BY APPLICANT This certifies that this application was completed by me, and that all entries on it and information in it are truthful and complete to the best of my knowledge. Signature:_____________________________________________ Date:___________________________ SAFETY PERFORMANCE HISTORY RECORDS REQUEST SECTION 1: ... TO BE COMPLETED BY PROSPECTIVE APPLICANT... I, (print name) ________________________________________________ ____________________ Social Security Number First, M.I. Last ___________ Date of Birth HEREBY AUTHORIZE Previous Employer: _____________________________________________________________ _ Email: _______________ Street:______________________________________________________________ Tele#: _______________ City, State, Zip _____________________ ___________________________________________________________Fax #: To release and forward the information requested by section 3 of this document concerning my Alcohol and Controlled Substances Testing records within the previous 3 years from ____________________________ _ (date of this application) To: Continuum Transportation Services, LTD. In compliance with Section 40.25 and 391.23(h), release of this information Attn: Safety Department / Driver Qualification must be made in a written form that ensures confidentiality, such as fax, 4500 Lee Rd. Suite 138 email or letter. Cleveland, Ohio 44128 P-216-518-4000 F-216-518-4030 _________________________________________ Applicants Signature This information is being requested in compliance with Section 40.25 and Section 391.23 SECTION 2: …TO BE COMPLETED BY PREVIOUS EMPLOYER... The applicant named above was employed by us. Employed as from (m/y) __________________________________ to (m/y) _________________________ _ 1. Did he/she drive motor vehicles for you? (yes) (no) If yes, what type? Straight truck(__) Tractor-semi trailer (__) Bus (__ ) Cargo Tank(__) Doubles/Triples (__) Other: __________ - 2. Reason for leaving your company: Discharged (__) Resignation (__) Layoff (__) Military Duty (__) If there IS no safety performance history to report, check here (__), sign below and return. Accidents: Complete the following for any accidents inc1uded on your accident register (section 390.I5(b) that involved the applicant in the 3 years prior to the application date shown above, or check here ( ) If there IS no accident register date for this driver. Date Location No. Injuries No. Fatalities Hazmat Spill 1. _____________________________________________________________________________________________________________________ 2. _____________________________________________________________________________________________________________________ 3. _____________________________________________________________________________________________________________________ Please provide information concerning any other accidents involving the Applicant that were reported to government agencies or insures or retained under internal policies: ___________________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ Any other remarks: ___________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________ Signature: ______________________________________________________ Date _______/________/_______ Title:___________________________________________________________ SECTION 3: …TO BE COMPLETED BY PREVIOUS EMPLOYER… DRUG & ALCOHOL HISTORY If the driver was not subject to Department of Transportation testing requirements while employed by this employer, please check here (_), fill in the dates of employment from __________ to_________________ , complete bottom of Section 3, sign, and retum. 1. Has this person had an alcohol test with a result of 0.04 or higher alcohol concentration? YES NO 2. Has this person tested positive or adulterated or substituted a test specimen for controlled substances? ( ) ( ) 3. Has this person refused to submit to a post-accident, random, reasonable suspicion, or follow-up alcohol or controlled sub- ( ) ( ) stance test? 4. Has this person committed other violations of Subpart B of Part 382, or Part 40? ( ) ( ) 5. If this person has violated a DOT drug and alcohol regulation, did this person complete a SAP prescribed rehabilitation ( ) ( ) program in your employ, including return-to-duty and follow-up tests? If yes, please send documentation back with this form. 6. For a driver who successfully completed a SAP's rehabilitation referral and remained in your employ, did this driver ( ) ( ) subsequently have an alcohol test result of 0.04 or greater, a verified positive drug test, or refuse to be tested? In answering these questions, include any required DOT drug or alcohol testing information obtained from prior previous em- ployers in the previous 3 years prior to the application date shown on page 1 Name: Company: __________________________ __________________________________________________________________________ Street: _____________________________ ________________________________ City, State, Zip: _____________________ Tele #: __________ Section Completed by: ________________ Date: __________ (signature) SECTION 4a: ... TO BE COMPLETED BY Continuum Transportation Services, LTD.… This form was (check one) (__) Faxed to previous employer (__) Mailed (__)Emailed) (__)Other: _________________________________ By: __________________________________________________________________________________Date: _______________________________ _ SECTION 4b: … TO BE COMPLETED BY Continuum Transportation Services, LTD.... Complete below when information is obtained. Information received from: _____________________________________________________________ Recorded by: _________________________________________________ Date: __________________________ METHOD ( ) Fax ( ) Mail ( ) Email ( ) Telephone ( ) Other If Other, Please explain: _________________________________ ..INSTRUCTIONS TO COMPLETE THE SAFETY PERFORMANCE HISTORY RECORDS REQUEST … SECTION 1: Prospective Applicant SECTION 2: Previous Employer • Complete the information required in this section • Complete the information required in this section • Sign and date the form • Sign and Date the form • Submit to Continuum Transportation Services, LTD. • Complete Section 3 SECTION 3: Previous Employer SECTION 4a: Continuum Transportation Services, LTD. • Complete the information required in this section • Complete the information & send to previous employer • Sign and Date the form • Return form to Continuum Transportation Services, LTD. SECTION 4b: Continuum Transportation Services, LTD. • Record receipt of information and retain file the form Continuum-Safety Dept Request for Check of Driving Record I hereby authorize you to release the following information to Continuum Transportation Services, LTD for purposes of investigation as required by Section 391.23 of the FMCSR. You are released from any and all liability which may result from furnishing such information. _____________________________/___/_____ Applicants Signature Date In accordance with the provisions of Section 604 and 607 of the Fair Credit Reporting Act, Public Law 91-508, as amended by the Consumer Credit Reporting Act of 1996 (Title II, Subtitle 0, Chapter I, of Public Law 104-208),1 hereby certify the following: I. The applicant has authorized in writing the procurement of this report; 2. The applicant has been informed in a separate written disclosure that a consumer report may be obtained for driver qualification purposes; 3. The information requested below will be used for a "permissible purpose" (i.e., information for qualification purposes) and will be used for no other purpose; 4. The information being obtained will not be used in violation of any federal or state equal opportunity law or regulation; and 5. Before taking an adverse action based in whole or in part on the report, the applicant will receive a copy of the requested report and the summary of consumer rights as provided with the report by the consumer reporting agency. I also hereby certify that this report request and the above applicant's release notice meet the definition of "permissible uses" of state motor vehicle records under the provisions of the Driver's Privacy Protection Act of 1994 (Public Law 103-322, Title XXX, Section 300002(a». __________________ __/___/_____ Applicants Signature Date TO: _________________________________________________________________________________________________________ _______________________________________________________________________________________ To Whom It Man Concern: The following named person has made application with our company for the position of INDEPENDENT CONTRACTOR/TRUCK DRIVER. As in accordance with Section 391.23 of the FMCSR, please furnish the undersigned with the applicant's record for the past three years. NAME OF APPLICANT: _____________________________________________________________________ ADDRESS: ________________________________________________________________________________ CITY/STATE: ________________________________________ Date of Birth: _____/______/_____ Social Security #: ______-_____-________ CDL#: _____________ ____________ STATE _____________________ _ REQUESTED BY Name: ____________________________ Continuum Transportation Services, LTD. 4500 Lee Rd. suite 138 Title: _____________________________ Cleveland, Ohio 44128 Signature: _________________________ ANNUAL REVIEW of DRIVING RECORD DRIVER NAME-________________________________________________________________________________ DRIVER ADRESS-______________________________________________________________________________ CITY-_________________________ STATE-____________________ZIP-________________________________ SOCIAL SECURITY # -_______________________________ START DATE-_______________________________________ INSTRUCTIONS TO CARRIER: Review the driving record of the truck driver/independent contractor in accordance with Section 391.25 and as outlined below. Complete the Certificate of Review as listed. Any remarks may be shown on the reverse side. In accordance with the Department of Transportation's Section 391.25 a motor carrier shall, at least once every 12 months, review the driving record of each driver to determine whether that driver meets minimum requirements for safe driving or is disqualified to drive a motor vehicle pursuant to Section 391.15. In reviewing a driving record, the motor carrier must consider any evidence that the driver has violated applicable provisions of the Federal Motor Carrier Safety Regulations and the Hazardous Materials Regulations. The motor carrier must also consider the driver's accident record and any evidence that the driver has violated laws governing the operation of motor vehicles, and must give great weight to violations, such as speeding, reckless driving, and operating while under the influence of alcohol or drugs, that indicate that the driver has exhibited a disregard for the safety of the public. CERTIFICATE OF REVIEW I have hereby reviewed the driving record of the above named driver in accordance with Section 391.25 and find them: (Check One) __________ Date Name of Person Reviewing Meets Minimum Is Disqualified to Drive a Requirements for Safe Motor Vehicle per 391.15 Driving REMARKS TO BE MADE ON REVERSE SIDE CONCERNING DISQUALIFICATION Continuum Transportation Services, LTD. Cleveland, Ohio UBSTANCE ABUSE COMPANY POLICY STATEMENT OF POLICY Continuum Transportation Services, LTD (hereinafter referred to as “Company”), because it is in the transportation business, has a compelling interest to eliminate the use of drugs and alcohol from its workplace. Since December 21st, 1989 for illegal drugs and January 1st, 1996 for alcohol, the company has a legal duty to prohibit employees who abuse these substances from working. This legal duty arises from the Department of Transportation regulations, specifically 49 CFR parts 382 and 391 and 49 CFR part 40. These employees are the Company’s employee drivers and independent contract drivers under contract with the Company for 90 days or more in any period of 365 days. These employees and independent contractors shall hereinafter be referred to as “drivers”. Illegal drug use, drug abuse and alcohol abuse jeopardizes the health and safety of the user, the user’s fellow drivers and the safety of the general public. A truck driver who uses or abuses drugs or alcohol is more likely to become involved in serious accidents. Thus, drug and alcohol abuse directly or indirectly increases absenteeism and reduces productivity. The adverse effects of illegal drug use, drug abuse and alcohol abuse result in increased insurance premiums. Finally, this company owes an obligation to its customers to handle their cargo safely, efficiently and on schedule, and drug and alcohol abuse undermines the accomplishment of this goal. While the Company has no intention of intruding into private lives, drivers are expected to be in condition to perform their duties throughout their workday. The Company recognizes that driver involvement with alcohol and drugs, off-the-job as well as on-the-job can have an impact on the workplace and on our ability to accomplish or goal of a work environment free from the effects of \alcohol and drug abuse. We have developed a substance abuse policy to help us combat illegal drug use, drug abuse and alcohol abuse in the workplace. This plan calls for administering urine/drug tests and alcohol breath tests to our drivers and drug tests to job applicants and to eliminate from our work force those drivers who abuse these substances. Equally important is our commitment to preserve the privacy and personal dignity of each driver and applicant as the Company reaches its goal of a drug and alcohol free workplace. The Company’s substance abuse policy is, specifically, as follows: USE PROHIBITED No driver will use alcohol or a Schedule 1 drug of the schedule of Controlled Substances of the Drug Enforcement Agency or an amphetamine, narcotic or any other habit forming drug except where permitted by the Federal Motor Carrier Safety Regulations. The schedule of drugs includes opiates, opium derivatives, hallucinogenic substances, depressants, and stimulants. This means that the driver shall not consume any controlled substances while off duty or on duty or alcohol while on-duty. No driver shall perform a safety sensitive function within four (4) hours after using alcohol. Any violation of the policy may result in discharge. IMPAIRMENT PROHIBITED No driver will report for work or will drive while impaired by any drug, controlled substance or alcohol. A driver may use a substance administered by or under the instructions of a physician who has advised the driver that the substance will not affect the driver’s ability to safely operate a motor vehicle. Impaired means under the influence of a substance such that the driver’s senses (i.e. sight, hearing, balance, and reaction, reflex) judgment either are or may be presumed affected. Any violation of the policy may result in discharge. POSSESSION PROHIBITED No driver at any work site will possess alcohol or any quantity of any controlled substance, lawful or unlawful, which in sufficient quantity could result in impaired performance, with the exception of substances administered by or under the instructions of a physician. “Work site” means any motor vehicle, office, building, yard or other property operated by a motor carrier, or any other location at which the driver is to perform work. “Possession” does not include possession of a substance, which is manifested and transported as part of a shipment. SUBSTANCE SCREENING For purposes of assuring compliance with the Federal Motor Carrier Safety Regulations and the Company’s policy, both current and new applicants for positions as drivers will be subject to drug and alcohol screening, whichever is applicable, under the circumstances described below. Substances screening means testing or urine for drugs and breath for alcohol to determine use or impairment. Applicants: Prior to assuming a driving position, any applicant will be subject to drug screening, Refusal to submit to such a screening will make it impossible to medically qualify the applicant, and the applicant will not be hired or leased. The substance screening of active drivers (including contract drivers) will be in accordance with the circumstances described below. Reasonable Cause Testing: When there is reasonable evidence to suspect a driver has reported to work or is working impaired, the driver may be subject to substance screening by a supervisor whom has been trained in drug and alcohol detections required by federal regulations. Refusal to submit to such screening will be considered as a positive test and result in termination of services. Post Accident Testing: Any driver in a “recordable accident” as defined by the Regulations of the U.S. Department of Transportation must submit to substance screening. Refusal to submit to a drug screen within 32 hours and an alcohol screen within 8 hours of a recordable accident will place the driver in violation of the Federal Motor Carrier Safety Regulations. No driver shall use alcohol for eight (8) hours following an accident if, the driver, is required to be tested because of the accident. If a fatal accident is involved, the driver will be disqualified to drive, for a one-year period, following a refusal to give a urine and breath sample. If the test results are positive, the driver is also disqualified to drive for one year. Random Testing: Drivers will be subject to substance screening at any time on a random basis, as a term and condition of holding a position as a driver. Any refusal by a driver to random screening will be treated as a positive test and the driver will not be qualified to drive with attendant consequences. After notification of a random test the driver has two (2) hours in which to complete the test. Failure to comply within this time frame will be treated as a positive test and result in termination of services. Alcohol testing may take place immediately prior to performing a safety-sensitive function, while performing a safety-sensitive function or immediately after performing a safety-sensitive function. Refusal to submitted alcohol testing, will be considered a positive test and result in termination of services. Test Results: The test results are reviewed to determine whether there is any indication of controlled substance or alcohol abuse. The results are confidential. The Company’s Medical Review Officer and designated company representative will be the only custodians of the individual test results. Assistance Program: When applicable, a choice of assistance Programs will be referred to help drivers solve drug or alcohol problems by providing educational information concerning the effects and consequences of drug or alcohol use on personal health, safety and work environment. The cost of this program will be the responsibility of the driver. Disciplinary Action (49 CFR 391.95) 1. Any driver who refuses to submit to a drug and alcohol test will not be permitted to operate a motor vehicle for the company. Further more such refusal will be treated as a positive test result and the service of the driver will be TERMINATED. 2. When a driver’s drug or alcohol screen test result is positive and the test was performed as either, reasonable cause or random testing, the following shall occur: a. The driver will be relieved of his/her duties immediately. b. The driver shall be suspended without pay. c. The driver shall be referred, “in confidence, to a choice of an assistance programs. d. The driver must have a “negative” return-to-duty test results and continuous “negative” follow-up test results (if applicable). e. If a driver fails to complete the suggested rehabilitation program or test positive in any future drug test. His lease will be terminated or employment terminated. f. Until a “negative” test result is achieved, the driver cannot perform any safety sensitive functions g. Drivers found to have an alcohol concentration of .02 or greater but less than .04 will be immediately removed from any safety-sensitive function and suspended, without pay, for 48 hours. h. .04 Or above will result in a suspension without pay and will be required to attend a session with a drug abuse professional. Driver Signature _________________________________________________ Designated Company Representative Name__________________________________ Location________________________________ *Training information on drugs and alcohol is available to any driver upon request.
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