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Driver Qualification

New Driver File Application

Paducah, KY 42001
Fax: 567-283-5171

Check List For All New Drivers
- Copy of Driver's License (correct for operation)
- Current MVR
- Pre-employment Drug Screen Results (CDL Only – Not required for Non-CDL drivers)
- Date of Hire
- Copy of Medical Card/Long Form Physical
- Verification From Your Insurance Carrier
- Completed Road Test (Any driver with a CDL is qualified to administer a road test)
- Qualification File Completed (Dated the day the driver fills out)
Optional Requirements
- Hazmat Training (HM-126/HM-232, or HM225 For Propane)
- Entry Level Driver Training (For all drivers that received their original CDL after June 20, 2003)
- LCV Training (For drivers that will pull doubles/triples combination vehicle)
All drivers are to complete a Qualification file
All pages that contain a red asterisk * are to be filled out in their entirety; failure to complete will delay the completion process.
File is to be returned to DOTOSHA Consulting LLC as soon as they are completed. Due to the stringent regulations, background checks are to be completed within 30 days after hire, we must receive the file as soon as possible. Failure to complete on time could result in violations from an audit.
Drivers Name*
First Last
License Type (please check one)*
- CDL Class A: Any combination of vehicles with a combined gross weight rating of 26001 lbs or more, if the gross vehicle weight rating of the trailer being towed is in the excess of 10,000 lbs.
- CDL Class B: Any single vehicle with a gross vehicle weight rating of 26001or more or any such vehicle having a gross vehicle weight rating that is not in excess of 10001 lbs
- CDL Class C: Any single vehicle, or combination of vehicles, that is not a Class A or B, but that either is designed to transport 16 or more passengers, including the driver, or is placarded for hazardous materials and any school bus with a gross vehicle weight rating of less than 26,001 lbs, that is designed to transport fewer than 16 passengers including the driver.
- Operator/Chauffer: Any combination that is over 10001 pounds up to 26000 lbs
CDL A Examples:
CDL B Examples:
CDL C Examples:
Driver applicant, please answer the following:
Does the vehicle have air brakes?*
- Yes
- No
Will you be hauling a tank over 1000 gallon capacity?*
- Yes
- No
Will you be driving Doubles/Triples?*
- Yes
- No
Will you be hauling propane?*
- Yes
- No
Will you be carrying Passengers? (15 or more)*
- Yes
- No
Prior to use of any new driver, you must make sure that the driver is properly qualified and has no restrictions that may disqualify him/her.
Application for Employment
In compliance with Federal and State equal employment opportunity laws, qualified applicants are considered for all positions without regard to race, color, religion, sex, national origin, age, marital status, or the presence of a non-job related medical condition or handicap.
#
Company Name*
Company Address*
Street Address City State / Province / Region ZIP / Postal Code
Date (Please use the date that you are filling out application)*
MM slash DD slash YYYY
Name*
Social Security #*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Is the above address the same for the preceding three years?*
- Yes
- No
Phone*
Email*
Date of Birth*
Can you provide proof of age?*
- Yes
- No
Have you had an accident in the last three years?*
- Yes
- No
Accident #1:
Date (Recent First)
Accident Details
Fatalities
Injuries
Accident #2:
Date
Accident Details
Fatalities
Injuries
Have you had any traffic convictions/forfeitures within the last three years?*
- Yes
- No
Traffic conviction/forfeiture #1:
Date (Recent First)
Location
Charge
Penalty/fine
Traffic conviction/forfeiture #2:
Date
Location
Charge
Penalty/fine
Traffic conviction/forfeiture #3:
Date
Location
Charge
Penalty/fine
Have you ever been denied a license, permit or privledge to operate a motor vehicle?*
- Yes
- No
Has your license, permit or privledge ever been suspended or revoked? (If yes, please give details below)*
- Yes
- No
Details
Have you had any POSITIVE Drug/Alcohol test(s) within the last six mont? (If yes, please give details below)*
- Yes
- No
Details
Have you had any criminal/felony convictions in the last five years? (If yes, please give details below)*
- Yes
- No
Details
All driver applicants must provide the following information for the preceding 10 YEARS
Most Recent Employer*
From (MO/YR)*
To (MO/YR)*
Address*
Street Address City State ZIP Code
Phone*
Contact*
Reason for Leaving*
Safety Sensitive Function (Driver)*
- Yes
- No
Subject to Part 40 (Drug & Alcohol)*
- Yes
- No
Recent Employer*
From (MO/YR)*
To (MO/YR)*
Address*
Street Address City State ZIP Code
Phone*
Contact*
Reason for Leaving*
Safety Sensitive Function (Driver)*
- Yes
- No
Subject to Part 40 (Drug & Alcohol)*
- Yes
- No
Recent Employer*
From (MO/YR)*
To (MO/YR)*
Address*
Street Address City State ZIP Code
Phone*
Contact*
Reason for Leaving*
Safety Sensitive Function (Driver)*
- Yes
- No
Subject to Part 40 (Drug & Alcohol)*
- Yes
- No
Recent Employer*
From (MO/YR)*
To (MO/YR)*
Address*
Street Address City State ZIP Code
Phone*
Contact*
Reason for Leaving*
Safety Sensitive Function (Driver)*
- Yes
- No
Subject to Part 40 (Drug & Alcohol)*
- Yes
- No
Recent Employer*
From (MO/YR)*
To (MO/YR)*
Address*
Street Address City State ZIP Code
Phone*
Contact*
Reason for Leaving*
Safety Sensitive Function (Driver)*
- Yes
- No
Subject to Part 40 (Drug & Alcohol)*
- Yes
- No
Driver's License Information
State*
State
License No.*
Class / Endorsements*
Expiration Date (MO/YR)*
Driving Experience
Straight Truck
From (MO/YR)
To (MO/YR)
Approximate Number of Miles
Tractor Trailer
From (MO/YR)
To (MO/YR)
Approximate Number of Miles
Doubles/Triples
From (MO/YR)
To (MO/YR)
Approximate Number of Miles
Other
From (MO/YR)
To (MO/YR)
Approximate Number of Miles
To be read and signed by applicant (section 391.23)
(g) After October 29, 2004, previous employers must:

(1) Respond to each request for the DOT defined information in paragraphs (d) and I of this section within 30 days after the request is received. If there is no safety performance history information to report for that driver, previous motor carrier employers are nonetheless required to send a response confirming the non-existence of any such data, including the driver identification information and dates of employment.

(2) Take all precautions reasonably necessary to ensure the accuracy of the records.

(3) Provide specific contact information in case a driver chooses to contact the previous employer regarding correction or rebuttal of the data.

(4) Keep a record of each request and the response for one year, including the date, the party to whom it was released, and a summary identifying what was provided.

(5) Exception. Until May 1, 2006, carriers need only provide information for accidents that occurred after April 29, 2003.(h) The release of information under this section may take any form that reasonably ensures confidentiality, including letter, facsimile, or e-mail. The previous employer and its agents and insurers must take all precautions reasonably necessary to protect the driver safety performance history records from disclosure to any person not directly involved in forwarding the records, except the previous employer’s insurer, except that the previous employer may not provide any alcohol or controlled substances information to the previous employer’s insurer.

(i)(1) The prospective employer must expressly notify drivers with Department of Transportation regulated employment during the preceding three years—via the application form or other written document prior to any hiring decision—that he or she has the following rights regarding the investigative information that will be provided to the prospective employer pursuant to paragraphs (d) and I of this section:

(i) The right to review information provided by previous employers;

(ii) The right to have errors in the information corrected by the previous employer and for that previous employer to re-send the corrected information to the prospective employer;

(iii) The right to have a rebuttal statement attached to the alleged erroneous information, if the previous employer and the driver cannot agree on the accuracy of the information.
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 authorize you to make such investigations and inquiries of my personal, employment, financial, or medical history and other related matters as may be necessary in arriving at an employment decision. (Generally, inquiries regarding medical history will be made only if and after a conditional offer of employment has been extended) I hereby release employers, schools, health care providers and other persons from all liability in responding to inquiries and releasing information in connections with my application.

In the event of employment, I understand that false or misleading information giving in my application or interview(s) may result in discharge. I understand, also that I am required to abide by all rules and regulations of the Company, as permitted by law.
Signature*
Date*
MM slash DD slash YYYY
Must an employer check on the drug and alcohol testing record of employees it is intending to use to perform safety-sensitive duties?
(a) Yes, as an employer, you must, after obtaining an employee’s written consent, request the information about the employee listed in paragraph (b) of this section. This requirement applies only to employees seeking to begin performing safety-sensitive duties for you for the first time (i.e., a new hire, an employee transfers into a safety-sensitive position). If the employee refuses to provide this written consent, you must not permit the employee to perform safety-sensitive functions.

(b) You must request the information listed in this paragraph (b) from DOT-regulated employers who have employed the employee during any period during the two years before the date of the employee’s application or transfer:
(1) Alcohol tests with a result of 0.04 or higher alcohol concentration;
(2) Verified positive drug tests;
(3) Refusals to be tested (including verified adulterated or substituted drug test results);
(4) Other violations of DOT agency drug and alcohol testing regulations; and
(5) With respect to any employee who violated a DOT drug and alcohol regulation, documentation of the employee’s successful completion of DOT return-to-duty requirements (including follow-up tests). If the previous employer does not have information about the return-do-duty process (e.g., an employer who did not hire an employee who tested positive on a pre-employment test), you must seek to obtain this information from the employee.
Employer Name*

is required to ask the following questions:
(1) Have you ever tested positive, or refused to test, on any Pre-employment drug or alcohol test administered by a previous employer to which you applied for, but did not obtain, safety sensitive transportation work covered by a DOT agency drug and alcohol testing rules during the past (2) years?*
- Yes
- No
If yes, you must provide a completed return to duty process!
Drivers License Requirements Driver Certification
Parts 383 and 391 of the Federal Motor Carrier Safety Regulations in regards to your commercial driver’s license, and you must comply with what is stated below:
1. Possess only one license:
  Drivers with a CDL must only have one in possession
  If you have more than one license, you must notify each corresponding state and close it; simply destroying the license will not rectify the problem.
2. Notification of license SUSPENSION, REVOCATION or CANCELLATION
  Section 391.15(b) AND 383.33 of the Federal Motor Carrier Safety Regulations require that you notify your employer the NEXT BUSINESS DAY of any revocation or suspension to your driver’s license. In addition, section 383.31 requires that any time you violate a state or local traffic law (other than parking), you must report it within 30 days to: your employing motor carrier, and the state that issued your license (if the violation occurs in a state other than the state that issued your license).This notification must be made in writing.
Driver's License Number*
State*
State
Expiration Date (MO/YR)*
Was the date of your original CDL issued after June 20, 2003?*
- Yes
- No
Date of Original CDL Issue*
I certify that I have read and understand the above requirements.
Name*
First Last
Signature*
Date*
MM slash DD slash YYYY
Safety Performance History Records Request
Section 1: Authorization
I, [insert name below] hereby authorize:*
Previous Employer:*
Email
Address
Street Address City State ZIP Code
Phone
Fax
to release and forward the information requested by section 3 of this document concerning my Alcohol and Controlled Substance Testing records within the previous 3 years from
Date of Employment Application

Date of Employment Application
to:
Prospective Employer:*
Attn:
Address
Street Address City State ZIP Code
Phone*
In compliance with 49 CFR §§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 letter.
Prospective employer's confidential fax number:
- 567-283-5171
Prospective employer's confidential email
- jmuratore@dotosha.com
Applicant's Signature*
Date*
MM slash DD slash YYYY
Section 2: Accident Histories
The applicant named above was employed by us.*
- Yes
- No
Employed as
From (MM/YY)
To (MM/YY)
Did he/she drive motor vehicle for you?
- Yes
- No
If yes, what type?
- Straight Truck
- Tractor/Semitrailer
- Bus
- Cargo Tank
- Doubles/Triples
Accidents
Complete the following for any accidents included on your accident registrar (§390.15(b)) that involved the applicant in the 3 years prior to the application date shown above, or select "no" below if there is no accident register data for this driver.
Is there accident register data for this driver?*
- Yes
- No
Location
Date
Number of Injuries
Number of Fatalities
Location
Date
Number of Injuries
Number of Fatalities
Please provide information concerning any other accidents involving the applicant that were reported to government agencies or insurers or retained under internal company policies:
Signature*
Title*
Date
MM slash DD slash YYYY
Section 3: Drug & Alcohol History
Was the driver subject to Department of Transportation testing requirements while employed by this employer?*
- Yes
- No
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?*
- Yes
- No
3. Has this person refused to submit to post-accident, random, reasonable suspicion, or follow-up alcohol or controlled substance test?*
- Yes
- No
4. Has this person committed other violations of Subpart B or Part 382 or Part 40?*
- Yes
- No
5. If this person has violated a DOT drug and alcohol regulation, did this person fail to undertake or or complete a program prescribed by a Substance Abuse Professional (SAP) in your employ If yes, please send documentation back with this form.*
- Yes
- No
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?*
- Yes
- No
In answering these questions, include any required DOT drug or alcohol testing information obtained from prior previous employers in the previous 3 years prior to the application date shown on page 1
Name*
First Last
Company*
Address*
Street Address City State ZIP Code
Phone*
Section Completed By (Signature)*
Date*
MM slash DD slash YYYY
Section 4: Mode of Communication
This form was sent to previous employer via (select one)
- Fax
- Mail
- Email
Section 5: Receipt Information
Complete the following when the requested information is obtained.
Information received from:
Recorded by:
Date
MM slash DD slash YYYY
Method
- Fax
- Mail
- Email
- Phone
Instructions
Section 1 Prospective employee
Complete highlighted areas, return to prospective employer
Section 2 Previous employer
Complete section, Sign and Date
Section 3 Previous employer
Complete section, Sign and Date
Section 4 Prospective employer
Document mode of communication, make a copy & keep on file.
Section 5 Prospective employer
Document receipt from previous employer, place in file & keep for 3 years after employee leaves

Contact Us



5050 Leonard Futrell Rd.
Paducah, KY 42001



270.415.5201

Driver Application File

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heading goes here

Driver Qualification

New Driver File Application

All drivers are to complete a Qualification file

Application for Employment

Accident #1:

Accident #2:

Traffic conviction/forfeiture #1:

Traffic conviction/forfeiture #2:

Traffic conviction/forfeiture #3:

All driver applicants must provide the following information for the preceding 10 YEARS

Driver's License Information

Driving Experience

To be read and signed by applicant (section 391.23)

Drivers License Requirements Driver Certification

Safety Performance History Records Request

Section 1: Authorization

Section 2: Accident Histories

Section 3: Drug & Alcohol History

Section 4: Mode of Communication

Section 5: Receipt Information

Instructions

Contact Us