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    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:

    State

    Number

    Expiration Date

    State

    Number

    Expiration Date

    State

    Number

    Expiration Date


    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 YesNo

    Date

    Violation

    State

    Commercial VehicleYesNo

    Date

    Violation

    State

    Commercial VehicleYesNo

    Date

    Violation

    State

    Commercial VehicleYesNo

    Date

    Violation

    State

    Commercial VehicleYesNo

    Date

    Violation

    State

    Commercial Vehicle YesNo

    Date

    Violation

    State

    Commercial VehicleYesNo

    Date

    Violation

    State

    Commercial VehicleYesNo

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

    YesNo

    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?

    YesNo

    Were you subject to 49 part 40 controlled substance and alcohol testing during this period?

    YesNo

    Reason for Leaving:

    Employer

    Dates

    Address

    Supervisor

    Telephone

    Were you subject to the Federal Motor Carrier Safety Regulations during this period?

    YesNo

    Were you subject to 49 part 40 controlled substance and alcohol testing during this period?

    YesNo

    Reason for Leaving:

    Employer

    Dates

    Address

    Supervisor

    Telephone

    Were you subject to the Federal Motor Carrier Safety Regulations during this period?

    YesNo

    Were you subject to 49 part 40 controlled substance and alcohol testing during this period?

    YesNo

    Reason for Leaving:

    Employer

    Dates

    Address

    Supervisor

    Telephone

    Were you subject to the Federal Motor Carrier Safety Regulations during this period?

    YesNo

    Were you subject to 49 part 40 controlled substance and alcohol testing during this period?

    YesNo

    Reason for Leaving:

    Employer

    Dates

    Address

    Supervisor

    Telephone

    Were you subject to the Federal Motor Carrier Safety Regulations during this period? YesNo

    Were you subject to 49 part 40 controlled substance and alcohol testing during this period? YesNo

    Reason for Leaving:

    Employer

    Dates

    Address

    Supervisor

    Telephone

    Were you subject to the Federal Motor Carrier Safety Regulations during this period? YesNo

    Were you subject to 49 part 40 controlled substance and alcohol testing during this period? YesNo

    Reason for Leaving:

    Employer

    Dates

    Address

    Supervisor

    Telephone

    Were you subject to the Federal Motor Carrier Safety Regulations during this period? YesNo

    Were you subject to 49 part 40 controlled substance and alcohol testing during this period? YesNo

    Reason for Leaving:

    Employer

    Dates

    Address

    Supervisor

    Telephone


    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.

    Prime TRANSPORT

    Contact: Parmbir Singh Deol
    Title: Chief Executive Officer
    Phone: 925-978-6751

    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?>

    YesNo

    Have you successfully completed the return-to-duty process


    YesNo

    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

    Company:

    Date: