SEI/Aaron’s Inc DOT Regulated Driver Qualification File Checklist Driver Name: _______________________________Soc. Sec. # : ________________ Facility # :________ Today’s Date: ____________ Hire Date: ____________ Job Title: ____________ State: _____________
Required Documents
Notes/Comments
Initial when complete
1) Copy of Drivers License (legible)
2) DOT Driver Application
3) Request for Information from Previous Employers (3 years of previous employment) 4) Consent To Obtain Consumer Report
5) Medical Examiners Report 6) Medical Certificate with Expiration Date
7) Record of Road Test
8) Certificate of Road Test
9) Motor Vehicle Report
1
SEI/Aaron’s Inc Driver Application for Employment Instructions Each application form must be completed by the applicant, must be signed by the applicant, and contain the following information
The applicant’s name, address, date of birth, and social security number The addresses at which the applicant has resided during the three years preceding the date on the application Indicate the date on which the application was submitted The issuing state, number, and expiration date of each unexpired motor vehicle operator’s license or permit that has been issued to the applicant Describe the nature and extent of the applicant’s experience in the operation of motor vehicles, including the types of motor vehicles that applicant has operated A list of all motor vehicle accidents in which the applicant was involved during the three years preceding the date the application was submitted, specifying the date and nature of each accident and any fatalities or personal injuries it caused A list of all violations of motor vehicle laws or ordinances (other than parking) of which the applicant was convicted or forfeited bond or collateral during the three years preceding the date of the application A statement setting forth in detail the facts and circumstances of any denial, revocation, or suspension of any license, permit, or privilege to operate a motor vehicle that has been issued to the applicant or a statement that no such denial, revocation, or suspension has occurred A list of the names and addresses of the applicant’s employers for 3 years preceding the date of application for which the applicant was an operator of a commercial motor vehicle, together with the dates of employment and the reason for leaving such employment The following certification and signature line, which must appear at the end of the application form and be dated and signed by the applicant: “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.”
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SEI/Aaron’s Inc. For internal use only: Hire Date: __________________ Hiring Location: _______________________________
DRIVER’S APPLICATION FOR EMPLOYMENT (Please use pen) {Your Company Name Here} is an equal opportunity employer and does not discriminate in any aspect of employment on the basis of race, color, religion, sex, pregnancy, sexual orientation, national origin, marital status, age, ancestry, veteran status, physical or mental disability, or any other legally protected status. Please exclude any information, which may indicate your race, color, religion, sex, pregnancy, sexual orientation, national origin, marital status, ancestry, veteran status, physical or mental disability, or any other legally protected status.
Position applied for__________________________
Date of application ____________________
Name _________________________________________ Social Security Number_________________ Last First Middle (List addresses of residency for the past three years) Current Address_________________________________________________________________________________ Street City ____________________________________________________________ How long ____________ State Zip Phone Number Previous Address____________________________________________________________ How long ____________ Street City State Zip
Previous Address____________________________________________________________ How long ____________ Street City State Zip
Previous Address____________________________________________________________ How long ____________ Street City State Zip
Date of Birth (required for commercial drivers) ________________Can you provide proof of age? _________________ Are you now employed? _________________ If not, how long since leaving last employment? ___________________
Have you ever been convicted of a felony or misdemeanor other than a minor traffic violation? [ ] YES [ ] NO If yes, please explain (a conviction is not an absolute bar to employment but will be considered as it relates to fitness and ability to perform the job._____________________________________________________________________________ _________________________________________________________________________________________________
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Accident History Accident record for past 3 years or more (attach sheet if additional space is needed). If none, write NONE Nature of accident (Head on, rear-end, upset, etc.)
Dates
Fatalities
Injuries
Traffic Convictions and Forfeitures Traffic Convictions and forfeitures for the past 3 years (other than parking violations). If none, write NONE Location
Date
Charge
Penalty
(Attach sheet if additional space is needed)
License Information Section 383.21 FMCSR states “No person who operates a commercial vehicle shall at any time have more than one driver license”. I certify that I do not have more than one motor vehicle license, the information for which is listed below ____________ State
________________________ License Number
________________ Type
__________________ Expiration Date
Have you ever been denied a license, permit, or privilege to operate a motor vehicle? [ ]YES
[ ]NO
Has any license, permit, or privilege ever been suspended or revoked? [ ]YES [ ]NO If the answer to A or B is YES, attach statement-giving details.
Driving Experience (if none, write NONE) Class of Equipment
Type of Equipment (Van, Tank, Flat, Etc.)
Approximate Number of Miles (Total)
Dates From
To
Straight truck Tractor and Semi Trailer Tractor—two trailers Motorcoach—School bus Other List States operated in for the last 5 years ______________________________________________________________ Show special courses or training that will help you as a driver _______________________________________________ Which safe driving awards do you hold and from whom? ___________________________________________________
Education Information School Name – High School, College, Technical
City
State
Graduated [ ]YES [ ]NO [ ]YES [ ]NO [ ]YES [ ]NO [ ]YES [ ]NO
If you did not graduate from high school, did you complete the G.E.D.? [ ] YES
[ ] No 2
Employment History All driver applicants must provide the following information on all employers and periods of unemployment during the preceding three years. List complete mailing address, street number, city, state, and zip code. List employers in reverse order starting with the most recent. Add another sheet as necessary. Employer Name
From Mo.
Address
Position Held
City
State
Contact Person
Zip Phone
Yr.
To Mo.
Yr.
Salary/Wage Reason for leaving
Were you subject to the FMCSR’s* while employed by this employer?
Yes
No
Was your job designated as a safety sensitive function in any DOT regulated mode subject to alcohol and controlled substances testing requirements as required by 49 CFR part 40?
Yes
No
Employer Name
From Mo.
Address
Position Held
City
State
Contact Person
Zip Phone
Yr.
To Mo.
Yr.
Salary/Wage Reason for leaving
Were you subject to the FMCSR’s* while employed by this employer?
Yes
No
Was your job designated as a safety sensitive function in any DOT regulated mode subject to alcohol and controlled substances testing requirements as required by 49 CFR part 40?
Yes
No
Employer Name
From Mo.
Address
Position Held
City
State
Contact Person
Zip Phone
Yr.
To Mo.
Yr.
Salary/Wage Reason for leaving
Were you subject to the FMCSR’s* while employed by this employer?
Yes
No
Was your job designated as a safety sensitive function in any DOT regulated mode subject to alcohol and controlled substances testing requirements as required by 49 CFR part 40?
Yes
No
Employer Name
From Mo.
Address
Position Held
City Contact Person
State
Zip Phone
Yr.
To Mo.
Yr.
Salary/Wage Reason for leaving
Were you subject to the FMCSR’s* while employed by this employer?
Yes
No
Was your job designated as a safety sensitive function in any DOT regulated mode subject to alcohol and controlled substances testing requirements as required by 49 CFR part 40?
Yes
No
*FMCSR – Federal Motor Carrier Safety Regulations
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Employment History Continued All driver applicants must provide the following information on all employers and periods of unemployment during the preceding three years. List complete mailing address, street number, city, state, and zip code. List employers in reverse order starting with the most recent. Add another sheet as necessary. Employer Name
From Mo.
Address
Position Held
City
State
Contact Person
Zip Phone
Yr.
To Mo.
Yr.
Salary/Wage Reason for leaving
Were you subject to the FMCSR’s* while employed by this employer?
Yes
No
Was your job designated as a safety sensitive function in any DOT regulated mode subject to alcohol and controlled substances testing requirements as required by 49 CFR part 40?
Yes
No
Employer Name
From Mo.
Address
Position Held
City
State
Contact Person
Zip Phone
Yr.
To Mo.
Yr.
Salary/Wage Reason for leaving
Were you subject to the FMCSR’s* while employed by this employer?
Yes
No
Was your job designated as a safety sensitive function in any DOT regulated mode subject to alcohol and controlled substances testing requirements as required by 49 CFR part 40?
Yes
No
Employer Name
From Mo.
Address
Position Held
City
State
Contact Person
Zip Phone
Yr.
To Mo.
Yr.
Salary/Wage Reason for leaving
Were you subject to the FMCSR’s* while employed by this employer?
Yes
No
Was your job designated as a safety sensitive function in any DOT regulated mode subject to alcohol and controlled substances testing requirements as required by 49 CFR part 40?
Yes
No
Employer Name
From Mo.
Address
Position Held
City Contact Person
State
Zip Phone
Yr.
To Mo.
Yr.
Salary/Wage Reason for leaving
Were you subject to the FMCSR’s* while employed by this employer?
Yes
No
Was your job designated as a safety sensitive function in any DOT regulated mode subject to alcohol and controlled substances testing requirements as required by 49 CFR part 40?
Yes
No
*FMCSR – Federal Motor Carrier Safety Regulations
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Experience and Qualifications—Other Show any trucking, transportation, or other experience that may help in your work for this company:
_________________________________________________________________________________________________ _________________________________________________________________________________________________ List education, training courses and prior military other than those shown elsewhere in this application:
_________________________________________________________________________________________________ _________________________________________________________________________________________________
List special equipment or technical materials you can work with (other than those already shown):
_________________________________________________________________________________________________ _________________________________________________________________________________________________
TO BE READ AND SIGNED BY APPLICANT Please read this section. 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
I understand and agree that {Your Company Name} or its authorized representative may verify all information furnished in this application. I waive any right I may have to be notified by any individuals and organizations named in this application prior to the release of any information to {Your Company Name}. I further authorize all individuals and organizations named in this application to give {Your Company Name} all information relative to such verification. I hereby release such individuals and organizations and {Your Company Name} from any and all liability for any claim or damage resulting therefrom.
I understand that {Your Company Name} is not obligated to provide employment and that I am not obligated to accept employment. Nothing in this application, or in any prior or subsequent oral or written statement, is intended to create any contract of employment or to create any rights in the nature of a contract of employment. This application does not bind either party for a specific period of time regarding employment. If hired, nothing in this application shall restrict my right as an employee or {Your Company Name} right as an employer to terminate my employment at any time.
Signature (sign, do not print)______________________________________________________ Date____________________
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SEI/Aaron’s Inc. Request for Information from Drivers Previous Employer The below named applicant is being considered for employment with {Your Company Name} and has listed your organization as a former employer. Per 391.23, 382.413 / 40.25 and 390.5 of the Federal Motor Carrier Safety Regulations, potential employers must obtain verification and previous employers must furnish information on employment, drug and alcohol testing results, and vehicle accidents from the previous three years. This information must be obtained within 30 days of a safety-sensitive function performed by the driver. Please furnish this information within the regulated time frame. Information provided will be treated in confidence. Applicant Name
Social Security #
Previous Employer
Telephone #
Address
Fax #
City
State / Zip
Applicant Signature
Date
Record of Employment (To be completed by previous employer) Position held:
________________________________
Dates employed: From____________To____________ (Mo./Yr.)
(Mo./Yr.)
What type of equipment driven: Tractor/trailer_____ Straight Truck_____Doubles_____Other_____ Accident information: A list of all accidents as defined in 390.5 of the FMCSR (Until May 1, 2006, carriers need only provide information for accidents that occurred after April 29, 2003) Date of accident/s: __________ (Use back of form to supply information for multiple accidents) City or town, or most near, where accident occurred and the State: _______________________________________ Number of injuries: __________ Number of fatalities: ___________ Were hazardous materials, other than fuel spill from the fuel tanks of motor vehicle involved in the accident, released? __ Furnish copies of all accident reports required by State or other governmental entities or insurers Has this person ever tested positive for drugs or alcohol?
[ ]YES
[ ] NO
Has this person ever refused to submit to a drug or alcohol test?
[ ]YES
[ ] NO
Has this person ever had an alcohol test with a Breath Alcohol Concentration? of 0.04 or greater in the past two years?
[ ]YES
[ ] NO
Has applicant violated any other DOT agency’s drug and alcohol regulations?
[ ]YES
[ ] NO
Have you received information from a previous employer that this applicant Violated any DOT drug and alcohol regulations?
[ ]YES
[ ] NO
If you answered YES to any of the above drug and alcohol questions, please provide the name and phone number of the contact that can confirm test dates and results_________________________________________________________ To your knowledge, was this driver’s license suspended while in your employ? _____If so, explain_______________ Printed name and title of person supplying information___________________________/_______________________ Signature of person supplying information_____________________________________________________ Title_________________________ Date_____/_____/_____
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SEI/Aaron’s Inc. Request for Information from Drivers Previous Employer The below named applicant is being considered for employment with {Your Company Name} and has listed your organization as a former employer. Per 391.23, 382.413 / 40.25 and 390.5 of the Federal Motor Carrier Safety Regulations, potential employers must obtain verification and previous employers must furnish information on employment, drug and alcohol testing results, and vehicle accidents from the previous three years. This information must be obtained within 30 days of a safety-sensitive function performed by the driver. Please furnish this information within the regulated time frame. Information provided will be treated in confidence. Applicant Name
Social Security #
Previous Employer
Telephone #
Address
Fax #
City
State / Zip
Applicant Signature
Date
Record of Employment (To be completed by previous employer) Position held:
________________________________
Dates employed: From____________To____________ (Mo./Yr.)
(Mo./Yr.)
What type of equipment driven: Tractor/trailer_____ Straight Truck_____Doubles_____Other_____ Accident information: A list of all accidents as defined in 390.5 of the FMCSR (Until May 1, 2006, carriers need only provide information for accidents that occurred after April 29, 2003) Date of accident/s: __________ (Use back of form to supply information for multiple accidents) City or town, or most near, where accident occurred and the State: _______________________________________ Number of injuries: __________ Number of fatalities: ___________ Were hazardous materials, other than fuel spill from the fuel tanks of motor vehicle involved in the accident, released? __ Furnish copies of all accident reports required by State or other governmental entities or insurers Has this person ever tested positive for drugs or alcohol?
[ ]YES
[ ] NO
Has this person ever refused to submit to a drug or alcohol test?
[ ]YES
[ ] NO
Has this person ever had an alcohol test with a Breath Alcohol Concentration? of 0.04 or greater in the past two years?
[ ]YES
[ ] NO
Has applicant violated any other DOT agency’s drug and alcohol regulations?
[ ]YES
[ ] NO
Have you received information from a previous employer that this applicant Violated any DOT drug and alcohol regulations?
[ ]YES
[ ] NO
If you answered YES to any of the above drug and alcohol questions, please provide the name and phone number of the contact that can confirm test dates and results_________________________________________________________ To your knowledge, was this driver’s license suspended while in your employ? _____If so, explain_______________ Printed name and title of person supplying information___________________________/_______________________ Signature of person supplying information_____________________________________________________ Title_________________________ Date_____/_____/_____
1
SEI/Aaron’s Inc. Request for Information from Drivers Previous Employer The below named applicant is being considered for employment with {Your Company Name} and has listed your organization as a former employer. Per 391.23, 382.413 / 40.25 and 390.5 of the Federal Motor Carrier Safety Regulations, potential employers must obtain verification and previous employers must furnish information on employment, drug and alcohol testing results, and vehicle accidents from the previous three years. This information must be obtained within 30 days of a safety-sensitive function performed by the driver. Please furnish this information within the regulated time frame. Information provided will be treated in confidence. Applicant Name
Social Security #
Previous Employer
Telephone #
Address
Fax #
City
State / Zip
Applicant Signature
Date
Record of Employment (To be completed by previous employer) Position held:
________________________________
Dates employed: From____________To____________ (Mo./Yr.)
(Mo./Yr.)
What type of equipment driven: Tractor/trailer_____ Straight Truck_____Doubles_____Other_____ Accident information: A list of all accidents as defined in 390.5 of the FMCSR (Until May 1, 2006, carriers need only provide information for accidents that occurred after April 29, 2003) Date of accident/s: __________ (Use back of form to supply information for multiple accidents) City or town, or most near, where accident occurred and the State: _______________________________________ Number of injuries: __________ Number of fatalities: ___________ Were hazardous materials, other than fuel spill from the fuel tanks of motor vehicle involved in the accident, released? __ Furnish copies of all accident reports required by State or other governmental entities or insurers Has this person ever tested positive for drugs or alcohol?
[ ]YES
[ ] NO
Has this person ever refused to submit to a drug or alcohol test?
[ ]YES
[ ] NO
Has this person ever had an alcohol test with a Breath Alcohol Concentration? of 0.04 or greater in the past two years?
[ ]YES
[ ] NO
Has applicant violated any other DOT agency’s drug and alcohol regulations?
[ ]YES
[ ] NO
Have you received information from a previous employer that this applicant Violated any DOT drug and alcohol regulations?
[ ]YES
[ ] NO
If you answered YES to any of the above drug and alcohol questions, please provide the name and phone number of the contact that can confirm test dates and results_________________________________________________________ To your knowledge, was this driver’s license suspended while in your employ? _____If so, explain_______________ Printed name and title of person supplying information___________________________/_______________________ Signature of person supplying information_____________________________________________________ Title_________________________ Date_____/_____/_____
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RECORD OF ROAD TEST Instructions to examiner: Mark "S" all items the driver performs satisfactorily; use "U" where performance is unsatisfactory. Any item not evaluated, mark as N/A. Note remarks in Remarks section
Driver's Name ___________________________ Home Address __________________________________ SSN ________________________ License # ________________________ State _______ Class _______ Equipment Driven (truck / tractor) _________________________Trailer(s) __________________________ (Make and model) (Body type & length) Length of Test _____________________ miles from / in ____________________to ___________________ Start Time _____________ Finish Time _____________ Weather Conditions ________________________
PART 1 - PRE-TRIP INSPECTION AND EMERGENCY EQUIPMENT Checks general condition approaching unit Checks fuel, oil, water and for excessive oil on engine Tests steering, brake assist, tractor protection valve and parking brake Reviews and signs previous report Checks instruments for normal readings Checks dashboard warning lights for proper functioning
____ ____ ____ ____ ____
Cleans windshield, windows, mirrors, lights and reflectors ____ Checks horn, windshield wipers, mirrors, emergency equipment, reflectors, flares, fuses, tire chains (if necessary), fire equipment ____
____
PART 2 - COUPLING AND UNCOUPLING Couples without difficulty Connects glad hands to trailer to apply trailer brakes before coupling Raises landing gear fully after coupling Visually checks king pin assembly to be certain of proper coupling
____ ____ ____ ____
Connects glad hands and light line properly Assures that surface will support trailer before uncoupling Checks coupling by applying hand valve (trailer air supply valve) and gently applying pressure by trying to pull away from trailer
____ ____
____
PART 3 - PLACING VEHICLES IN MOTION AND USE OF CONTROLS A. MOTOR Place transmission in neutral before starting Engine Starts engine without difficulty Checks instruments at regular intervals Maintains proper engine rpm while driving
B. BRAKES ____ ____ ____ ____
C. CLUTCH AND TRANSMISSION Starts unit moving smoothly Uses clutch properly
Knows proper use of and checks tractor protection valve (trailer air supply valve) Tests service brakes Builds full air pressure before moving
____ ____ ____
D. LIGHTS (if tested at night) ___
___
Adjusts speed for range of headlights Dims Lights when approaching another vehicle or following other traffic
____
2
PART 4 - BACKING AND PARKING A. BACKING Gets out and checks area before backing Understands and utilizes mirrors properly Signals when backing from blind side Avoids backing from blind side
B. PARKING (CITY) ____ ____ ____ ____
C. PARKING (ROAD) Parks off pavement Secures unit properly Uses emergency warning signal or device when necessary
Parks without hitting any other vehicles or stationary objects Parks correct distance from curb Secures unit properly - sets parking brakes transmission in correct gear, shuts off engine, blocks wheels (when necessary) Carefully enters traffic from parked position
____ ____
____ ____
____ ____ ____
PART 5 - SLOWING AND STOPPING Uses clutch and gears properly Gears down properly before descending hills Starts without rolling back Tests brakes before descending grades
____ ____ ____ ____
Uses brakes properly on grades Makes proper use of mirrors Plans stop far enough in advance to avoid hard braking Stops clear of crosswalks
____ ____ ____ ____
PART 6 - OPERATING IN TRAFFIC< PASSING AND TURNING A. TURNING Signals intention to turn well in advance Gets into proper lane well in advance of turn Checks traffic conditions and turns only when intersection is clear Restricts traffic from passing on right when preparing to complete right hand turn Completes turn promptly and safely and does not impede other traffic
D. GRADE CROSSING ____ ____ ____ ____
____ ____
E. PASSING
____ ____ ____
Allows sufficient space ahead for passing ____ Passes only in safe locations ____ Signals changing lanes before and after passing ____ Warns driver ahead of intention to pass ____ Passes with sufficient speed differential to minimize obstructing traffic ____ Returns to right lane promptly but only when safe to do so ____
____
F. SPEED
____
Observes speed limits ____ Drives at speed consistent with ability ____ Adjusts speed properly to road, weather and traffic conditions ____ Slows down in advance of curves, danger zones and intersections ____ Maintains constant speed where possible ____
C. INTERSECTIONS Yields right of way Checks for cross traffic regardless of traffic controls Enters all intersections prepared to stop if necessary
____
____
B. TRAFFIC SIGNS AND SIGNALS Plans stop in advance and adjusts speed correctly Obeys all traffic signals Comes to complete stop at all stop signals
Stops at a minimum 15 feet but no more than 50 feet before crossing if stop is necessary Selects proper gear and does not shift gears while crossing Knows and understands federal and state rules governing grade crossings
____
3
G. COURTESY AND SAFETY Yields right of way Consistently strives to drive in a safe manner
____ ____
Allows faster traffic to pass Uses horn only when necessary
____ ____
Checks instruments regularly while driving Personal appearance is professional Remains calm under pressure
____ ____ ____
PART 7 - MISCELLANEOUS A. GENERAL DRIVING ABILITY AND HABITS Consistently alert and attentive Consistently is aware of changing traffic conditions Anticipates problems Performs routine functions without taking eyes from the road
____ ____ ____ ____
B. USE OF SPECIAL EQUIPMENT (SPECIFY) ___________________________________
REMARKS:
____
_______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________
GENERAL PERFORMANCE ___Satisfactory
___Needs Training
Explanation: ___________________________________________________________________________
QUALIFIED FOR: ___Straight Truck
___Tractor/Semi-trailer
___Twin Trailers
___Other Combination
___Other (specify) ____________________________ Special Equipment: _______________________________
_____________________________________ Examiner's name - PRINT
_____________________________________ Examiners Signature
___________________________ Date
_______________________________
_______________________
Driver’s Signature
Date
4
CERTIFICATION OF ROAD TEST (Note: The Record of Road Test is used as a source document to complete this section and will be attached to this certification upon completion.) If the road test is successfully completed, the person who gave it must ensure that the original of this certification is sent to human resources to be placed in the person’s file and a duplicate copy of this road test certification is provided to the person examined. (391.31 (e) (f)(g)(1)(2) Federal Motor Carrier Regulations) Driver’s Name____________________________________________ SSN ___________________________ Operator’s or Chauffeur’s License No.______________________________ State______________________ Type of Power Unit_______________________________ Type of Trailer ____________________________ This is to certify the above named driver was given a road test under my supervision on _____/______/_____ (Date) Consisting of approximately ____________ miles of driving. It is my considered opinion this driver possesses sufficient driving skill to operate the type of commercial vehicle listed above. ______________________________________ Signature of Examiner
______________________________ Title
___________________________________ Company
_______________________________ Address of Examiner
_______________________________
_______________________
Driver’s Signature
Date
5
CERTIFICATION OF ROAD TEST Drivers Name __________________________________________ Operator's or Chauffeur's License No. _______________________ State ________ Type of Power Unit _________________________ This is to certify that the above-named driver was given a road test under my supervision on _____________________ 20_____ consisting of approximately ____________ miles of driving. It is my considered opinion that possesses sufficient driving skill to operate safely the type of commercial motor vehicle listed above __________________________ __________________________ Signature of examiner Title
Organization and address of examiner
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