FILL IN ALL BLANKS & PROVIDE ALL INFORMATION REQUESTED-PRINT OR TYPE

Date



First Name

Middle Name

Last Name

Current Address

Home Telephone

Cellular telephone

Date of Birth

Social Security Number

If your above address is less than 3 years continue listing them below to cover the previous 3 year period

Current Address

Date: From-To

Current Address

Date: From-To

Current Address

Date: From-To

Use backside of sheet for additional addresses


Driver,s License Information: all licenses held, last 3 years:

Expiration Date

State

Number

Expiration Date

State

Number

Expiration Date

State

Number


Experience:

Type of Vehicle Driver

To Date

Approximate Mileage Driven

Type of Vehicle Driver

To Date

Approximate Mileage Driven

Type of Vehicle Driver

To Date

Approximate Mileage Driven


All Accidents,last 3 year:(If none,write NONE)

Date

Describe

Fatalities

Injuries

Date

Describe

Fatalities

Injuries

Date

Describe

Fatalities

Injuries


List all Traffic Violations Convictions, last 3 year(If none,write NONE)

Date

Violation

State

Commercial Vehicle  Yes No

Date

Violation

State

Commercial Vehicle Yes No

Date

Violation

State

Commercial Vehicle Yes No

Date

Violation

State

Commercial Vehicle Yes No

Date

Violation

State

Commercial Vehicle Yes No

Date

Violation

State

Commercial Vehicle  Yes No

Date

Violation

State

Commercial Vehicle Yes No

Date

Violation

State

Commercial Vehicle Yes No


Have you ever had any driver license denied, suspended,revoked or canceled by any issuing state agency?

 Yes No

If yes: state of issuance; explanation


Emploment History,10 year(383.35)--account for gaps between employers:(If owner/operater,list carriers leased to)

Employer

Dates

Address

Supervisor

Telephone

Were you subject to the Federal Motor Carrier Safety Regulations during this period?  Yes No

Were you subject to 49 part 40 controlled substance and alcohol testing during this period?  Yes No

Reason for Leaving:


Employer

Dates

Address

Supervisor

Telephone

Were you subject to the Federal Motor Carrier Safety Regulations during this period?  Yes No

Were you subject to 49 part 40 controlled substance and alcohol testing during this period?  Yes No

Reason for Leaving:


Employer

Dates

Address

Supervisor

Telephone

Were you subject to the Federal Motor Carrier Safety Regulations during this period?  Yes No

Were you subject to 49 part 40 controlled substance and alcohol testing during this period?  Yes No

Reason for Leaving:

Employer

Dates

Address

Supervisor

Telephone

Were you subject to the Federal Motor Carrier Safety Regulations during this period?  Yes No

Were you subject to 49 part 40 controlled substance and alcohol testing during this period?  Yes No

Reason for Leaving:


Employer

Dates

Address

Supervisor

Telephone

Were you subject to the Federal Motor Carrier Safety Regulations during this period?  Yes No

Were you subject to 49 part 40 controlled substance and alcohol testing during this period?  Yes No

Reason for Leaving:


Employer

Dates

Address

Supervisor

Telephone

Were you subject to the Federal Motor Carrier Safety Regulations during this period?  Yes No

Were you subject to 49 part 40 controlled substance and alcohol testing during this period?  Yes No

Reason for Leaving:


Employer

Dates

Address

Supervisor

Telephone

Were you subject to the Federal Motor Carrier Safety Regulations during this period?  Yes No

Were you subject to 49 part 40 controlled substance and alcohol testing during this period?  Yes No

Reason for Leaving:


Use backside of sheet for additional addresses


For driver application motor vehicles that require a Commercial Driver License (CDL) the application must disclose their controlled substance and alcohol status per the requirements of 49 CFR part 40.25(j).


As a prospective drive employee, you have the right to review information provided by previous employers. You have the right to have error in the information corrected by the previous employer(s) and for that previous employer(s) to re-send the corrected information to the prospective employer; the right to have a rebuttal statment attched to the alleged erroneous information, if the previous employer and the driver cannot agree on the accuracy of the information

Driver employer who have previous Department of Transportation regulated employment history in the preceding three years, and wish to review previous employer provided investigative information, must submit a written request to the prospective employer, which may be done at anytime, including when applying or as late as thirty(30) days after being employer or being notified of denial of employment. The prospective employer must provide this information to the applicant within five(5) business days of receving the written request. I f the prospective employer has not yet received the requested information from the previus employer(s), then the five (5) business day deadlines will being when the prospective employer receives the requested safety performance history information.If the driver has not arranged to pick up or receive the requested records within thirty (30) days of the prospective employer making them available, the prospective motor carrier may consider the driver to have waived their request to review the records.


Certification

"I certify that this application was completed by me, and that all entries on it and information in it are true and completed to the best of my knowledge.

Application's Signature

Approximate


TO BE COMPLETED BY THE EMPLOYER:

Application received by:

Name

Title

Date

Applicaton reviewed for completeness by:

Name

Title

Date


SIGNIFICANT DATES:

Date of Hire

Time & Date of Pre-Employment CST:

Time & Date of Pre-Employment CST Result Received

Date First Used in Safety Sensitive Position

Date of Termination.

PRIMELINK EXPRESS INC

983 DRF CREEK PL

LATHROP CA 95330

209-252-0070


COMMERCIAL VEHICLE DRIVER APPLICANT

Controlled Substance and Alcohol Questionnaire

Pursuant to 49 CFR part 40.25(j)

Application Date

First Name

Middle Name

Last Name

Current Address

Home Telephone

Cellular telephone

Date of Birth

Social Security Number


49 CFR 40.25(j)

Have you ever tested, or refused to test, on any 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 DOT agency drug and alcohol testing rules during the past two years?

 Yes No

Have you successfully completed the return-to-duty process

 Yes No

Application's Signature

Date Signed


TO BE COMPLETED BY EMPLOYER

Received by

Title

Date

Received by

Title

Date

The Federal Motor Carrier Safety Regulations require all previous employers of this applicant to respond to this request for information within 30 days. Failure to comply with this request is in violation of 49CFR 391.23 and 40.25, for which you may be prosecuted. Questions concerning the requirements of this regulation should be directed to the Minnesota Division Office of the Federal Motor Carrier Safety Administration at 651-291-6150, during business hours.

TO

DATE

Mailing Address

Address

Telephone

Fax Number

I

Hereby authoriz

to release to all records of employment, including assessments of my job performance, ability, and fitness , including the dates of any and all alcohol or drug tests, with confirrmed results, and/or my refusal to submit to any alcohol and drug tests and any rehabilitation completion under direction of Substance Abuse Professionl(SAP) and/or Medical Review Offcer (MRO) to each and every company(or thier authorized agents) making such request in connection with my application for employment with said company. I, hereby,release the above named company, and its employees, officers, directore, and agents from any and all liability of any type as a result of providing the following information to the below mentioned person and/or company.

Applicant's Signature & Date

Witness's Signature & Date


REQUEST FROM

Company

Address

Telephone Number

Fax Number

Telephone Number

NAME OF APPLICANT

SSA

JOB APPLYING FOR


INQUIRY INTO EMPLOYMENT HISTORY,PRECEDING 3 YEAR

Did applicant work for you as a

From-To

YES or NO IF NO, please explain:

If employed as driver, please answer the following:

Company Driver

Owner/Operator

Other

Type of truck(s)and/or truck/tractor(s)operated:

Commodities transported

Area of operations

Accidents?YES or NO IF YES, please give date(s)and brief description of each accident

Accidents?Why did this employee leave your company?

Would ypu re-employ this person? YES or NO IF NO, please explain

Additional comments


INOUIRY FOR ALCOHOL AND CONTROLLED SUBSTANCES INFORMATION, PRECEDING 2 YEARS

Alcohol tests with a result of 0.04 or greater? ............... YES or NO if yes please give date(s):

Verified positive controlled substances test result? ..... YES or NO if yes please give date(s):

Refusals to be tested? ................................................... YES or NO if yes please give date(s):

Was rehabilitation completed as required? .................. YES or NO if yes please give date(s)


person providing the above information:

Name

Title

Name

Title