Motor Vehicle Driyer's
CERTI FICATISN O# COfVI PLIANCE
trlrlTH DRIVER LICENSE REQUIREMENTS
to e$eIY dfiver who operates in intrastate,
MOTOR CARRTER TNSTRUCflONS: The requirements in Part 383 applY
pounds or more, can transport morethan 15
interctate, orforeign cornnnerce and operates a vehicle weighing 26,001
people, or transports hazardous rnaterial that require placarding.
in interstate cornmerce and operates a vehicle
The requirements in part 3g1 apply to eyery driver who operates
people, or transpcrts hazardous materials that require
weighing 10,001 ponds or more, can transport mare than 15
placarding.
parts 3g3 and 3gl sf the fueral Motor carnersafety Regulations contain certain driuer
DRIVER REQUTREMENTS:
inchding the following:
licensing requirements that you as a driuer must cornply wkh,
1.)
2.1
oNE USENS& You,
motor vehide oPeratols license'
pOSSESS ONLy
as a commercial vehicle
driver, may ilot possess more tltan one
SECTION 391'15{BX2}
iTOTIFICATION OF UCEIIISE SUSPENSICI{, RET'OCATIOITI ORCAI{CETIATION:
require that ycu notify your employer
AND 3g3.33 OF THE Federal Motor carrier safuty Regulations
revocation or suspenslon of your driver's license- ln addition, section
a sfate or local traffic law {other than
3g3.31 requires that anytime you are convicted of violating
moturarrier, and 2) the state that
parking), you must report it within 30 days to: 1) your employing
t}an the one which issued your license}' The
issued your 1icense {if the violaiion occurs in a state other
the NDff
BUSINESS DAy of any
notificationtobothtfreemployerandstatemustbeinwriting.
3.i
38323 {ait2} requires that your commercial driver's license
you have Yourtrue' fixed' and permanent home and
be issued by your legal state of domicile, where
wheneveryou are absenl lf you
principal residence and io which you have the intension of retuming
to transfer your cDL w?thin 30 days'
a new dornicite in another ltate, you must apply
cD
L DOMTCILE REQUIREMEITITS: Secrlon
establish
The following license is the only one I possess:
Driver's License NoDRIVER CERTtFlcAnoN: I
State
Exp. Date
certifothat I have read and understood the abcve requirements'
Driver's Name (Printed):
Driver's Signature:
Notes:
Date:
HEQUEST FCIN &HHCK OF DRIVING NECORD
NOTE TO MOTOR CAHRIEH: SEE B,ACK SIDE FOR STATES THAT ACCEPTTHIS FoHM.
I hereby authorize you to release the following lnfonnailon io
(F
rospective Employer)
for purposes of investigation as required by Sections 391.23 and 391.25 of the Federal lyiotor Carrier SlrutV Regutations. you ar
released from any and all liability which may result from fumishing such information.
!aonl19an]
s sionatu re)
(Date)
ln accordance with the provisions of Sections 604 and 607 of the Fair Credit Reporting Aet, Public Law g1-508, as arnended b
the Consumer Credit Reporting Act of 1996 {Title ll, Subtitle D, Chapter 1, of Public Larr104-208), I hereby certify the foltowing:
1. The consumer (applicant) has authorized in writing the procurement of this repori;
2. The consumer (applicant) has been informed in a separate written disclosure that a consumer report may be obtained fc
employment purposes;
3. The information requested below will be used for a "permissible
4.
5.
purpose" (i.e., information for employment purposes) anr
will be used for no other purpose;
The information being obtained will not be used in violation of any federal or state equal opportunig law or regulation; and
Before taking an adverse action based in whole or in part on the report the consumer (applicant) will receive a copy of thr
requested report and the summary of consumer rights as provided with the report by the consumer reporting agency.
I also hereby certify that this report request and the above applicanfs release notice meet the definition of "permissible uses" o
state motor vehicle records under the provisions of the Driver's Privacy Protection Act of 1994 (Public Law 103-822, Tiile XXX
Section 300002(a)).
(Signature of Requester)
(Date)
TO:
DEAR SIF/MADAM:
[l
ff,e following named person has made application with our company for the position of
pr."* f,*i-r,, ** ,,d"d@;':r?,["Jfff:;#,$,::ffiH?fff,"i1?:1i""j,3n*"nu
I
rne following named person is employed with our company
of rransportation Regurations'
in the position of
pr""* rr*i,r, th",-d*,@;'ffi[T33tTrYffi:5:::J,::]:?Lfl"#
Department orrransportation Resurations'
NAME OF APPLICANT/DRIVEH
ADDRESS
(Number & Street)
(city)
(Staie)
(Zp Code)
(Number & Street)
(City)
(Siate)
(Zip Code)
FCRMER ADDRESS
DATE OF BIRTH
SSN
LICENSE NO.
REQUESTED BY
(Name of Company)
(Iyped Name)
(Address)
fiitle)
(city)
O CoDvrioht
2O12 J. J. KELLER & ASSOCIATES. lNC.€.
(State)
Nmnah. W . USA . f800) 327-6R64. iikcller cnm . Prinio.t in tho I toad Qr.ra.
(Signature)
MSTOR IfEHICI."E DRIVER'S
Certification of Violati,onsfinnual Review of Brivins Record
drtver it employs to prepare and fumish
at least once every 12 months, require each
MOTOR CARRTER lf,lSTRUCnoNS: Each motor carrier shall
which the drtuer has been
ordinances {other than violatiens involving parking} of
a w,.h a list of all violations of motor vehicle traffic raws and
391'2?}' Drivers who have
forfeited bond or collateral duringthe proceeding 12 months {section
convicted, or on accpunt of urhidr he/she has
information on th'ls form'
provided information by Section 383.31 need not repeat thai
been convicted
the list as required by the motor carrier above- lf tfre driuer has nct
DRIVER REeulRMENrs: Each driver shall fumish
be listed, he/she shall so certify {Section 391'27}'
forfe?ted bond. or eollateral on account of any violation which rnust
C0MPLEXED
*v Onlvse - GRfi
of or
FlC4IlOffi
have
required to be listed {other than those I
ce*ify thatthe following is a true and complete list of treffic violations
bond or collateral during the Fast 12 months'
provided under part 3g3) for which I have been convicted or forfeited
I
{lf you ftaa n" *i"frtiont,
:tt".L*
on account of
convicted of forfeited bond cr collateral
lf no violations are listed above, I ceftiry that I have not been
past 12 monthsunder Part 383} required to be listJd durtne the
any violation {other than those r have provided
in section 36L25 0f the
listed aboue and otherinfonnaticn described
lNSTUgnoNS: Review the certification of violations
the inforrnation requestd belou
Federal Motor canier Safety Regulations' complete
MOTOR CARRTER
that
driver in accordance '*ith section 391'?,5 and find
hereby reviewed the driving record of the above named
he/she {check one}:
a rnotorvehide pursuant to section 391'L5
tr Meets minirnum requirernents for safe driving nts disqualifiqd ip drrve
r have
trDoesnotadequatetymeetsatisFactorysafedrivingperformance
Action taken with driver:
Reviewed bY:
Date
Signature
I
Printed Name
MTE LOGISTICS, tlc
Motor Carrier Name
2435 Ffet HwY 3sr
Ivlotor Carrier Address
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i
INSURANIT AGENIY
SPECiALiZING IN IHAi{SPOBTATION INSURANCI
llatc:
To:
Fwples Insursace Agenry
FS B*x I lg
rffaverly, Iowa 5ffi?7-0n I g
Fromr:
I would like to request yolt ts order
individual:
a
lMatsr nfehicle R.ectrd {MXIR} for the fol}orving
Name:
D"L.#
i)08:
Statc:
Years Exprrience:
lrrtiividtral: I undcrstatrd that driving is a part oi'mr,.joh,Sescripiion. and I here br,
-rire
Perrnissiott t0 Peoples Insurance Agenc5 to acccss rrv metor rehicls records anil provide
a cop.r' to ntl'prospcctite r)r clurclll emplover.
Signature:.
IJat:
Narne:
Piease l'etilrn
t* l'liclre lle Jenison. frar.'is
Eggers^ *r Cole Heimer by f-ax ilr eurail
PH: 8$0-932-48{i1,[rax: it9-]52-63?8
il-mail:
E-nrail:
F -ruail:
l-eant
l
MTE LOGISTICS, LLC
PO BOX 4285
243 S. FM 35L
Beeaille, TX 78104
PH:
36l-352-Aru2
361-37.8-AruL
FAX:361-351-5229
Driaer's naftte:
Social Securiht:
I herby authorize
arcd request:
Company nfrme:.
Address:
TeleTthone:
Fax:
Drizter's signature:
Witnessed brt:
Date:
Required infornrution.from section 382.413 and 40.25(b)
1.
Has the aboae named indiztidual had an alcohol test with
a breath alcohol concentratiott of 0.A4 or greater zuhile
employed by your company?
yes
no
substance yes
flo
2. Has the abozte named indiaidual had a controlled
test with a positiae result while employed by your companq?
3.
Has the abozte named indiztidual refused a controlled
test while employe.d by tlour company?
4. Other aiolations of DOT agerxcy drug E alcohol
substance yes
testirrg
no
attacheil
non-attached
regulations?
Do Vou haae documentatiotr of the eruployees successfnl
completion of tlrc 49 CER subpart 0 rcturn to dutrl
requirements ?
5.
]\{Ttr
INT-
.lql)^1\
attached
non-attacherl