Source: http://wildwoodex.com/addemployeapplic.php
Timestamp: 2018-07-23 01:33:53
Document Index: 488556030

Matched Legal Cases: ['ARTS 40', 'ART 40', 'ART 40', 'ART 0', '§40', '§391', '§382', '§40', '§382', '§382', '§382', '§382', 'art 40']

Wild Wood Express | california truckload carriers | Add employee application Form
PREVIOUS ADDRESS IF CURRENT ADDRESS IS LESS THAN 3 YEARS:
DRIVER LICENSES HELD (PAST 3 YEARS)
LICENSE NUMBER TYPE STATE EXPIRATION DATE
TRAFFIC CONVICTIONS/FORFEITURES FOR THE PAST 3 YEARS (other than Parking violations)
ACCIDENT RECORD FOR THE PAST 8 WARS OR MORE (use additional sheet if necessary)
NATURE OF ACCIDENT(BEAD-ON, REAR-END, UPSET, ETC.
EXPERIENCE AND QUALIFICATIONS OF DRIVER
CHECK TYPE OF EQUIPMENT DATES
FROM (M/Y)	TO (M/Y) APPROXIMATE TOTAL MILES
Tractor/Two-Trailers Yes No
Tractor/Three-Trailers Yes No
Bus/School Bus Yes No
Entry Level Driver Training (less than one year experience) Yes No
Longer Combination Vehicle (LCV) Training Yes No
NOTE: THE REGULATIONS REQUIRE THAT EMPLOYMENT FOR AT LEAST 3 YEARS AND/OR COMMERCIAL DRIVING EXPERIENCE FORTHE PAST 10 YEARS BE SHOWN. THE PREVIOUS EMPLOYERS MAY BE CONTACTED AS PART OF THE HIRING PROCESS.
WAS YOUR JOB DESIGNATED AS A SAFETY-SENSITIVE FUNCTION IN ANY DOT-REGULATED MODE (COMMERCIAL DRIVER) SUBJECT TO THE FMCSR, PARTS 40 AND 3S2? Yes No
PREVIOUS PRE-EMPLOYMENT ALCOHOL AND CONTROLLED SUBSTANCES TESTING
* To Be Completed By Prospective Employee * *
THE FOLLOWING REQUESTED INFORMATION IS REQUIRED BY FEDERAL MOTOR CARRIER SAFETY REGULATION, TITLE 49, PART 40.25(J).
PLEASE READ THE FOLLOWING INFORMATION VERY CAREFULLY AND ANSWER THE QUESTIONS TO THE BEST OF YOUR KNOWLEDGE. FAILURE TO COMPLETE THIS QUESTIONNAIRE PRECLUDES ANY CHANCE OF EMPLOYMENT WITH THIS COMPANY
RELATIVE TO PRE-EMPLOYMENT SUBSTANCE ABUSE AND ALCOHOL MISUSE TESTING, AS A POTENTIAL EMPLOYEE APPLYING FOR A POSITION AS A COMMERCIAL MOTOR VEHICLE OPERATOR WITH ANY MOTOR CARRIER EMPLOYER, IN THE PAST TWO YEARS HAVE YOU:
TEST POSITIVE FOR SUBSTANCE ABUSE? Yes No
TREFUSED A SUBSTANCE ABUSE TEST? Yes No
TESTED POSITIVE FOR AN ALCOHOL MISUSE TEST? Yes No
REFUSED AN ALCOHOL MISUSE TEST? Yes No
IF YOU HAVE ANSWERED "YES" TO ANY ONE OF THE ABOVE QUESTIONS YOU SST PROVIDE THE FOLLOWING INFORMATION (FMCSR, PART 40, SUBPART 0):
YOUR SUBSTANCE ABUSE PROFESSIONAL (SAP):
Name Phoner Number
•	COPY OF YOUR SAP PROGRAM CERTIFYING COMPLETION OF ALL REQUIREMENTS OR
•	COPY OF YOUR SAP PROGRAM AND
•	COPY OF YOUR RETURN-TO-DUTY NEGATIVE TEST RESULT AND
•	COPY OF ALL YOUR FOLLOW-UP TESTS ADMINISTERED IN COMPLIANCE WITH YOUR SAP PROGRAM.
I CERFITY THAT THE ABOVE INFORMATION PROVIDED BY ME IS TRUE AND CORRECT
REQUEST/CONSENT FOR INFORMATION FROM PREVIOUS EMPLOYER
TME INFORMATION REQUESTED IS REQUIIIED BY FEDERAL MOTOR CARRIER SAFETY REGULATIONS, TITLE 49, SECTIONS 40.25 AND 391.23
Address Re:
City Sate Zip SSE#:
Period Of Employment Position Held:
I HEREBY AUTHORIZED YOU TO RELEAS/VERIFY ALL INFORMATION REGARDING MY IDENTIFICATION, EMPLOYMENT HISTORY, CHARACTER, CONDUCT, ALCOHOL AND CONTROLLED SUBSTANCES TESTING, AND ACCIDENT RECORD FOR THE PAST 3 YEARS TO:
IN COMPLIANCE WITH FMCSR §40.25(G) AND §391.23(H), RELEASE OF THIS INFORMATION MUST BE MADE IN A WRITTEN FORM THAT ENSURES CONFIDENTIALITY, SUCH AS FAX, EMAIL, OR LEITER. UNDER FMCSR 391.23(G), YOU MUST RESPOND wrrni 30 DAYS OF RECEIPT.
SECTION 2: PREVIOUS EMPLOYER TO COMPLETE AS IT PERTAINS TO FMSCR SECTION 40.25 / 891.28
IF DRIVER/EMPLOYEE WAS NOT SUBJECT TO §382 TESTING REQUIREMENTS WHILE EMPLOYED BY THIS EMPLOYER, PLEASE CHECK HERE , SIGN AT THE BOTTOM AND SKIP TO THE NEXT SECTION (Over),
HAS THIS PERSON VIOLATED ANY OF THE DRUG AND/OR ALCOHOL PROHIBITIONS UNDER FMCSR §40 OR §382 IN THE PAST THREE YEARS, INCLUDING:
1.	A controlled substance test result of positive, adulterated, or substituted (FMCSR §382.215) Yes No
2.	An alcohol test with a result of 0.04 or higher alcohol concentration (FMCSR §382.201) Yes No
3.	A refusal to submit to a random, post-accident, reasonable suspicion, or follow-up controlled substance or alcohol test (FMCSR §382.211) Yes No
4.	Has this person committed other violations if Subpart B of 382, or Part 40? Yes No
5.	If this person violated a DOT drug and/or alcohol prohibition, did he/she fail to begin or complete a rehabilitation program prescribed by a Substance Abuse Professional (SAP)? If	rehabilitation was required but you do not know if he/she began or completed such program check here . Yes No N/A
6. If this person successfully completed a SAP's rehabilitation referral and remained in your employ, did he/she subsequently have an alcohol test result of 0.04 or greater, a verified positive drug test, or refusal to be tested? Yes No N/A
SECTION 3: PREVIOUS EMPLOYER TO COMPLETE AS IT PERTAINS TO FMCSR SECTION
APPLICANT'S ACCIDENT RECORD FOR THE PREVIOUS 3 YEARS
DATE OF ACCIDENT LOCATION
CITY / STATE NUMBER OF INJURIES NUMBER OF FATALITIES HAZARDOUS MATERIALS ELEASED
(Other Than Fuel From Fuel Tanks)
SECTION 4: APPLICANTS PERFORMANCE HISTORY
QUALITY OF WORK EXCELLENT GOOD FAIR POOR
CO-OPERATION WITH OTHERS EXCELLENT GOOD FAIR POOR
DRIVING SKILLS EXCELLENT GOOD FAIR POOR
ATTENDANCE RECORD EXCELLENT GOOD FAIR POOR
Would you re-hire?
Did applicant have custody of money or valuables?
Was Driver's License ever suspended or revoked?
INSTRUCTIONS: MOTOR CARRIERS WHEN USING A DRIVER FOR THE FIRST TIME SHALL OBTAIN FROM THE DRIVER A EOM STATEMENT PINE THE TOTAL TIME ON-DUTY DIMINO THE WIED/ATELY PRECEDINO 7 DAYS AND TIME AT WHICH SUCH DRIVER WAS LAST RELIEVED FROM DUTY PRIOR TO BEGINNING WORK FOR SUCH CARRIER. SECTION 395.8(J) (2) OF THE FEDERAL MOTOR CARRIER SAFETY REGULATIONS. NOTE: HOURS FOR ANY COMPENSATED WORK DURING THE PRECEDING 7 DAYS, INCLUDING WORK FOR A NON-MOTOR CARRIER ENTITY, MUST BE RECORDED ON THIS FORM.
SOCIAL SECURITY No TYPE OF LICENSE
LICENSE No ISSUING STATE
I hereby certify that the information given above is correct to the best of my knowledge and belief, and that I was last relieved from work at on
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(8)(9) OF
THE FEDERAL MOTOR CARRIER SAFTY 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
Do you intend to work for another employer while employed with 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 (5) FOR COMPENSATION THAT I MUST INFORM THIS COMPANY IMMEDIATELY OF SUCH EMPLOYMENT ACTIVITY.
Permission to Obtain DMV Reports
Name of Job Applicant/Employee
City State Zip Date
Wildwood Express Inc
Dear Wildwood Express Inc.:
Department of Motor Vehicle reports may be obtained as part of the Wildwood Express Inc. evaluation of my job application/employment. The reports may be procured by DlBuduo & DeFendis Insurance Agency, and may include my driving record, to assess my insurability under the Company's insurance coverage's. By signing this disclosure, I hereby authorize the Company to procure such reports about me from time to time, as it deems appropriate, to evaluate my insurability.