9269 E. STATE ROAD 48 MILAN,IN 47031 800-322-9567X 570 YOU PROVIDEIN THIS APPLICATION YOU ARE HEREBYNOTIFIEDTHE INFORMATION WILL BE CONTACTED,FOR THE MAY BE USED,AND YOUR PREVIOUSEMPLOYERS PERFORMANCE HISTORYINFORMATION YOUR SAFETY PURPOSEOF INVESTIGATING (d) AND (e) of S 391.23.CFR. AS REQUIREDBY PARAGRAPHS YOUR RIGHTSREGARDINGCERTAININVESTIGATIVEINFORIT'IATION threeyearsfromthe date employment duringthe preceding all driverswithDOTregulated Pursuantto 49 C.F.R.S 391.23(iXl), of this applicationhave the followingrightsregardingthe investigativeinformationthat is providedto BAYLORTRUCKING, lNC.as required by 49 C.F.R.S 391.23(d)and(e). 1. 2. 3. The rightto reviewinformationprovidedby previousemployers/companies; and for the previous correctedby the previousemployer/company The rightto haveerrorsin the information to the prospectivecarrier;and to re-sendthe conectedinformation employer/company The rightto havea rebuttalstatementattachedto the allegederroneousinformation,if the previous employer/company and the drivercannotagreeon the accuracyof the information. o (FMCSR's) requireBAYLORTRUCKING, lNC.to obtainthe following The FederalMotorCarrierSafetyRegulations informationon yourapplicationfor lease: duringthe 10 yearsprecedingthe dateof the 1. The name(s)and addressees)of youremployer(s)/companies application; 2. The datesyou were employedby that employer(s)or leasedto that company; or terminatingyour lease; The reasonfor leavingthe employof your previousemployer(s) 3. Whetheryou were subjectto the FMCSR'swhileemployedby your previousemployer(s)or leasedto your 4. prevrous company. Whetheryourjob was designatedas a safetysensitivefunctionin any DOT regulatedmodesubjectto alcohol 5. as set forthby 49 C.F.R.part40. and controlledsubstancestestingrequirements . from the followinginformation BAYLORTRUCKING,lNC.is alsorequiredby 49 C.F.R.S 391.23(d)to investigate your previousemployer(s)or companyif you wereemployedor contractedto operatea commercialmotorvehicle: 1. and employmentor leasecontractverificationinformation; Generaldriveridentification you thatoccurredin the involving 2. The dataelementsas specifiedin 49 C.F.R.S 390.15(b)(l) for accidents ten year periodprecedingthe dateof your leaseapplication; Any accidentsdefinedby 49 C.F.R.$ 390.15;and 3. 4. Any accidentsthe previousemployer/company may wish to providethat are retainedpursuantto 40 C.F.R.$ internalpolicyfor retainingmoredetailedminoraccident 390.15(bX2) or pursuantto the employer's/company's information. . Additionally,49 C.F.R. S 391.23(e)providesthat BAYLORTRUCKING,lNC. must investigatethe following informationfrom all previous DOT regulatedemployers/company's that employedyou or entered into a lease agreementwith you in a safetysensitivefunctionthat requiredalcoholand controlledsubstancetestingspecifiedin 49 C.F.R.part40: prohibitions Whetherwithin under 1. the previous10 yearsyou haveviolatedthe alcoholandcontrolsubstances 49 C.F.R.S 382 programprescribedby a substanceabuse 2. Whetheryou failedto undertakeor completea rehabilitation professional; and lf you successfullycompleteda substanceabuse professional's rehabilitationreferraland remainedin the 3. on whetheryou had the followingtestedviolationssubsequentto employof the referringemployer,information the completionof the referral: i. Alcoholtestswith a resultof 0.04or higheralcoholconcentration; Verifiedpositivedrugtests;and ii. iii. Refusalsto be tested(includingverifiedadulteratedor substituteddrugtest results). with yourwrittenconsentto releasethe information BAYLORTRUCKING,lNC. mustprovideyour previousemployer/company on paragraph(e). lf you refuseto providethiswrittenconsent,BAYLORTRUCKING,lNC. cannotpermityou to operatea commercialmotor vehicle or enter into a lease agreement. R E V IS E D012910 Dateof Application: BaylorTrucking,Inc. 9269 E. State Road 48 Mil?n,lN 470 41 800-322-9567 Signatureof Contractor Fax: 812-623-4622 ng.com ortrucki recruiting@bayl Recruiter: withoutregard for all positions areconsidered applicants laws,qualified withfederalandstateequalopportunity In compliance origin,maritalstatus,andnon-jobrelateddisability. sex,national to race,religion, I understandthe informationI provideregardingcurrentand/orpreviousemployersor companiesto which I was leasedmay be used, and the employer(s)or comoaniesto which I was leasedwill beiontacted, for the purposeof investigatingmy safetyperformancehistoryas requiredby 49 CFR 391.23(d)and (e). I also understandI have the right to: . o . Reviewinformationprovidedby previousemployersor companiesto which I was leased. Have errorsin the informationcorrectedby previousemployersor companiesto which I was leasedand for those previousemployersor comoaniesto which I was leasedre-sendthe correctedinformationto the prospectiveemployer,and Have a rebuttalstatementaftachedto the allegederroneousinformation,if the previousemployer(s)or companiesto which I was leased and I cannotagree on the accuracyof the information. Position: IndependentGontractor Driver/Owner tr Na m e or Driverfor lndependentGontractor n Dateof Birth First Last CurrentAddress I State EMAILADDRESS: Soc. Sec. # Home Phone(-) -ffiT- -City I MI zip How Long I T,o Cell Phone(_) EmergencyContactand Phone FORTHEPASTTHREE(3)YEARS(FMCSR391.2(b)(3): ADDRESSES PREVTOUS Previous Address Long) PreviousAddress (How Long) PreviousAddress (How Long) or proofof yourlegalrightto liveandworkin this lf leasedto BaylorTrucking,Inc.,can you presentevidenceof yourU.S.Citizenship country?lyes E no Haveyou appliedfor work and/orworkedfor or beenleasedto this companybefore? EYes n No lf yes, when? fl Other I TruckDrivingPublication ReferralE Newspaper Howdid youfindoutaboutBaylorTrucking?! Employee PLEASEREAD CAREFULLY A. E Yes E No to operatea motorvehicle? Haveyou everbeendenieda licensepermitor privilege a. ! Yes E No C. ! Yes E No or revoked? Hasany license,permitor privilegebeensuspended Haveyou everbeenchargedwitha DUI/OWI? D. E Yes n No Haveyou ever beenconvictedof a crime involvinga motorcarrier? E. E Yes E No Haveyou everbeenconvictedof leavingthe sceneof an accident? F. fl Yes E No Haveyou ever beenconvictedof a felony? G. E Yes E No tt. E Yes E tto or randomtest. Haveyou ever had a positivetest resultor refusedto take a drug or alcoholpre-employment Do you currentlyhaveany criminalactionspendingin whichyou area defendant? lf you answered yes to any of the above, state the circumstances,date and State EDUCATION C irc let he h i g h e s t g r a d e c o mp le te d 1 2 3 4 5 6 7 B Hig h S chool 1 2 3 4 C ol l ege 12 3 4 DrivingSchool:n Yes n ruo City GraduationDate State MILITARY Have you ever served in the U.S. Armed Forces? fl yes fI No R ank Branch Dates: From To DRIV]NGEXPERIENCE Classof Equipment Approx.No. of Miles From Type of Equipment Van-Tank-Flat, etc. StraiqhtTruck Semi-TractorlTrailer Tractor- Doubles Other LICENSE LTcENSES HELDrNpAsr FrvEyEARs Llsr ALLDRrvERs STATE TYPE LICENSENUMBER ENDORSEMENTS EXPIRATIONDATE NoNE. MOVINGTRAFFIG CONVICTIONS LISTFoRPASTFIVE(il YEARS.IFNoNEWRITE DATE LOCATIONSTATE CHARGE PENALTY vEHlcLEANDpERSoNAL vEHrcLErNcLuDrNG ACCIDENT RECORD tF NoN wRlrE NoNE. Lrsr ALLrNvoLvEMENr wrrH coMMERclAL PREVENTABLE ACCIDENTS AT FORMER PROPERTY DAMAGE FORPASTFIVEYEARS.INCLUDE ANDNON.PREVENTABLE EMPLOYERS. DATE VEHICLETYPE PRIVATEOR COMMERCI AL NATUREOF ACCIDENT INDICATE FATALITIES INJURIES PREV/NON-P DAMAGEAMOUNT ( HEADON, REAR END,UPSET ,ET C. A CLASS.AMOTORVEHICLEIN THEPASTFIVEYEARS. STATESIN WHICHYOU HAVEOPERATED LISTALL STATES: RECORDFORPAST10 YEARS EMPLOYMENT All applicantsmust list all full and part{ime employmentor companiescontractedto includingmilitaryservice,selfin reverse duringthe preceding10 years. Note; List employers/companies and periodsof unemployment employment, with the most recent. orderstarting Mo Yr Mo Yr Gurrentor Most Recent Emploveror Companv MayWe Call? YES Name NO From To Reason for Leaving_ Supervisor Address Street City State Zip Trailer PositionHeld Phone TractorDriven # Accidents From Gap in Employment to Explain Were you subjectto the FederalMotorCarrierSafetyRegulationswhile employedby this previousemployer? Yes A. FMCSR 391.21(bX1OXiv)(A) B. FMCSR391.21(bX1oxiv)(B)Was this job designatedas a safetysensitivefunctionin any DOT regulatedmode subjectto alcoholand controlled substances testing required by 49CFR paft40? Yes No No Mo Yr Mo Yr Second Prior Emploveror Companv To From Name Reason for Leaving Address Supervisor Street City State ZiP Trailer PositionHeld Phone From Gap in Employment to rractorDriven # Accidents Explain Were you subjectto the FederalMotorCarrierSafetyRegulationswhile employedby this previousemployer? Yes A. FMCSR 391.21(bX1OXiv)(A) Was this job designatedas a safetysensitivefunctionin any DOT regulatedmode subjectto alcoholand controlled B. FMCSR 391.21(bX10Xiv)(B) substances testing required by 49CFR part40? Yes No Mo Yr Third Prior Emploveror Companv Mo Yr To From Name Reason for Leaving Address Supervisor Street City State ZiP From Gap in Employment to rractorDriven Trai l er PositionHeld Phone No # Accidents Explain Were you subjectto the FederalMotorCarrierSafetyRegulationswhile employedby this previousemployer? Yes A. FMCSR 391.21(bX10Xiv)(A) Was this job designatedas a safetysensitivefunctionin any DOT regulatedmode subjectto alcoholand controlled B. FMCSR 391.21(bX1OXiv)(B) substancestestingrequiredby 49CFR parl4O? Yes No Mo Yr Fourth Prior Emploveror Gompanv From Na me No Mo Yr To Reason for Leaving Supervisor Address Street Phone From Gap in Employment City State rractor Driven Trailer PositionHeld to ZiP Explain # Accidents Were you subjectto the FederalMotorCarrierSafetyRegulationswhile employedby this previousemployer? Yes A. FMCSR 391.21(bX10Xiv)(A) Was this job designatedas a safetysensitivefunctionin any DOT regulatedmode subjectto alcoholand controlled B. FMCSR 391.21(bX10Xiv)(B) substancestestingrequiredby 49CFR part40? Yes No No Mo Yr Fifth Prior Emploveror Gompanv Mo Yr From Name Reason for Leaving Supervisor Address Street City State Z ip Trailer PositionHeld Phone From Gap in Employment to TractorDriven # Accidents Explain A. FMCSR 391.21(bX1OXiv)(A) Were you subjectto the FederalMotorCarrierSafetyRegulationswhile employedby this previousemployer? Yes Was this job designatedas a safetysensitivefunctionin any DOT regulatedmode subjectto alcoholand controlled B. FMCSR 391.21(bX1OXiv)(B) substancestestingrequiredby 49CFR part 40? Yes No Mo Yr Sixth Prior Emplover or Companv Mo Yr To From Name No Reason for Leaving Address Supervisor Street City State zip Trailer PositionHeld Ph o ne Gap in Employment From to Tractor Driven # Accidents Explain A. FMCSR 391.21(bX1OXiv)(A) Were you subjectto the FederalMotorCarrierSafetyRegulationswhile employedby this previousemployer? Yes B. FMCSR 391.21(bX10Xiv)(B) Was this job designatedas a safetysensitivefunctionin any DOT regulatedmode subjectto alcoholand controlled substances testinq required by 49CFR part40? Yes No Mo Yr Seventh Prior Emploveror Gompanv Mo Yr To From Name No Reason for Leaving_ Supervisor Address Street Phone City State z ip PositionHeld Gap in EmploymentFrom to Tractor Driven Trailer # Accidents Explain A. FMCSR 391.21(bX1OXiv)(A) Were you subjectto the FederalMotorCarrierSafetyRegulationswhile employedby this previousemployer? Yes B. FMCSR 391.21(bX1OXiv)(B) Was this job designatedas a safetysensitivefunctionin any DOT regulatedmode subjectto alcoholand controlled substancestestingrequiredbv 49CFR part 40? Yes No Mo Yr Eighth Prior Emploveror Gompanv From Name No Mo Yr To Reason for Leaving Address Supervisor Street Phone Gap in EmploymentFrom City State Tractor Driven Trailer PositionHeld to zip Explain # Accidents Were you subjectto the FederalMotorCarrierSafetyRegulationswhile employedby this previousemployer? Yes A. FMCSR 391.21(bX10Xiv)(A) B. FMCSR 391.21(bX10Xiv)(B) Was this job designatedas a safetysensitivefunctionin any DOT regulatedmode subjectto alcoholand controlled substancestestingrequiredby 49CFR part 40? Yes No No . r o o r o . . r o . o MINIMUM QUALIFICATIONS present appearance Must a clean,well-groomed Minimum24yearsof age MusthaveonlyoneCDL,ClassA, issuedby stateof residence (tenyears) frompastemployers Verifiablereferences "Nofalsifications mustaccurately reflectall periodsof on application". Application or incorrectinformation for the pasttenyears military, andunemployment self-employment, training, employment, withinthe pastthreeyears,no multiple offenses No DUIdrivingconvictions withinthe pastthreeyears No recklessdrivingconvictions substances or derivatives thereof for possession, saleor useof narcoticdrugs,controlled No convictions in thepastthreeyearsandno morethanfivein the for movingviolations No morethanthreecitations pastfouryears No majorpreventable accidentwithinthe pastthreeyears,and no morethantwo minoraccidentsi incidents passDOTphysical roadtest,mustsupplyvalidSSN anddrugscreen,alongwitha certified Successfully card,anddriver'slicensewithphotograph. froma certifiedPTDISchool Minimumof oneyearexperience, verifiable over-the-road, or graduated AND PHYSICALREQUIREMENTS JOB DESCRIPTION A successfulcandidatefor any commercialdrivingpositionor leasecontractor(as definedin 49 CFR Part 391)for qualifications, BaylorTruckingmust,in addition to meeting theminimum be ableto performallof thefollowing tasks: JOBOVERVIEW: Safelydrivea conventional tractorpullinga 53-footvan trailerthroughout the UnitedStatesas required,basedon the availability of freightand hoursavailableaccordingto the hoursof serviceregulations, Part395,FederalMotorCarrier SafetyRegulations.ln additionto driving,you may be requiredto loadand unloadtrailers,hookand unhookfrom trailers,performdailypre-tripand post-tripinspections of equipment and someminormaintenance and repair. You mustaccuratelymaintainall requiredpaperworkincludinglogbook,deliveryand pay sheets,and workwith on-board communications. PHYSICAL REQUIREMENTS: fn additionto meetingthe minimumphysicalrequirements set out in Part391.41ofthe FederalMotorCarrierSafety Regulations, a successful candidatemustbe ableto performthefollowing: LIFTING/ CARRYING:50 to 100pounds,distances for up to 100feet CLIMBING:lnto andoutof tractorcabs& trailers/ loadingdocks PULLING:Full strengthhorizontally movetandems to hookandunhooktrailers/ PUSHING:Full strengthhorizontally, up to 15 poundsvertically BENDING:(Other repeatedly thanlifting), eachday CRAWLING OR CROUCHING:15 minuteseachday WALKING:Up to 500feetseveraltimesa day STANDING:3 to 4 hourson occasion LYINGDOWN:8to 10 hoursperdayin sleeperberth SITTING:Up to 15 hoursdaily MANUALDEXTERITY:Operation of truckcontrolsandcomputerkeyboard MATH:Able to do andunderstand simplemath(addition andsubtraction) ENGLISH:Able to read,writeandunderstand the Englishlanguage lf hired,would you be able to performall the job tasks outlinedin the job descriptionand physicalrequirements? YES NO (tF NO, EXPLATN WHY) lf not, what accommodationswould you need to performthese essentialtasks? card? YES or certification Do you havean originallong-formD.O.T.physicalcertificate lf yes,pleaseattacha copy. NO 9269 E. STATE ROAD 48 MILAN,IN 47031 800-322-9567X 570 APPLICANT TO BE READANDSIGNEDBY CONTRACTOR thatwith my signaturebelowI herby: and understand acknowledge (PrintYour Name) AuthorizeBaylorTrucking,Inc or its agentsto investigatemy background,character,generalreputationand prioremploymentby contactingmy prioremployer'sreferencesor any other individualsBaylorTrucking,Inc. considersnecessaryincludingcompaniesI have been previouslyleasedto. of my personal, AuthorizeBaylorTrucking,Inc.or its agentsto make such inquiriesand investigations may necessary in arrivingat be employment,driving,financialor medicalhistoryand otherrelatedmattersas (Generally, history will be made only if and after a conditional inquiries regarding medical contractdecision. offer of a contracthas been extended.) Releasemy previousemployers,companies,schools,healthcare providersand otherpersonsfrom liabilityin respondingto inquiriesand releasinginformationin connectionwith my application. Authorizemy prioremployers,referencesand any otherindividualscontactedby BaylorTrucking,Inc.to releaseany and all informationrequestedand absolvethose partieswho provideinformationrequestedfrom any and all liabilityrelatedto theirdoingso. Acknowledgethat any contractagreementofferedto me is at the will of BaylorTrucking,Inc.; said contract may be terminatedby BaylorTrucking,Inc.at any time,with or withoutcause. Acknowledgethat I will be requiredand agreeto submitto a physicalexaminationand testingfor drug use as partof BaylorTrucking,Inc.evaluationproceduresand authorizereleaseof my resultsto BaylorTrucking,Inc. use of thoseresultsin decidingwhetherI shouldbe offereda lease and give BaylorTrucking,Inc. unrestricted agreement. Acknowledgeand agree that an expressconditionof my lease agreementis that I stay drug-freeand promptly submitto randomdrug testingwheneverrequiredby BaylorTrucking,Inc. Acknowledgeand agree that evidenceof drug use prior to or during my contractlease will be groundsfor immediateterminationof my leasewithoutrecourse. Certifythis applicationwas completedby me and acknowledgethat all entrieson it and the information providedis true, accurateand completeto the best of my knowledge. Acknowledgethat providingfalse,misleadingor incompletestatementsin this applicationof or in connection with the evaluationby BaylorTrucking,Inc.of me as a candidatefor independentcontractoris groundsfor immediateterminationof my lease,regardlessof when such informationis discovered. ApplicantSignature Print Date Reviewed& WitnessedBy: Title | | Verification PastEmployment/Contract BaylorTrucking,Inc. 9269 E. State Road 48 Milan,lN 4704 1 800-322-9567 I herebyauthorizeall my previousemployersor any othercarrierto give BaylorTrucking,Inc.,all the informationregardingmy services,character, conductand all informationon my Alcoholand ControlledSubstances testing. I releaseall TestingffrainingRecord,includingpre-employment my previousemployersor any othercarrierfrom any liabilitywhichmay resultfrom givingsuch information. Fax: 812-623-4622 [email protected] Number security sociat III-II-EIII Name Date Signature (Noteto Applicant- Pleasedo not writebelowthis line.) Please take a moment and complete the information requested in Part 2, We would appreciate your prompt response. As you are aware, after October 29,2004, failure to respond within 30 days to investigate requests for safety performance history will result in a complaint notification being filed with the Federal Motor Garrier Safety Administration using the complaint process specified in 49 CFR Part 386.12. Employer/Carrier Phone Address Fax City zip State Title/Position Contact 1. Date employed/contracted: 2. JobTitle: from to I from I tol Equipment Driven: ECompanyDriver IOrn IOwner Operator f] negional IOriver for OwnerOp llocal Esingle ITeam Istuoent 3. Reasonfor leavingyour company. [Discharge ltractor Trailer fstraight Truck I gus nResignation EReefer/Dry Van Inatbed Ifanker [Military Duty nlayoff 4. Would this applicantbe consideredfor employmenUlease with your companyagain?lYes f]No 5. lf there is no safety performancehistoryto report,check here n, sign below and return. flUpon Review ACCIDENT HISTORY: Pleasegive the followinginformationfor any accidentsincludedon your accidentregister(Part 390.15(b)that involvedthe applicant(regardlessof fault)which occurredin the previousthree (3) years. Or check here E, if there is no accidentregisterdata for this applicant. Date City State Description # lnjuries PrevllNonP # Fatalities HazMatSpill Ivrs Iruo Ivrs Iruo Evrs fruo Pleaseprovideany otheraccidentinformationinvolvingthe applicantwhich is retainedunderinternalcontrolpolicies: The above named individualhas advisedus he/sheworkedfor your companyor he/sheappliedto your companyfor work duringthe previousthree years. Pursuantto FMCSR 391.21(bX10)pleasegive the followinginformationfor this applicant.The informationyou providewill be held in strict confidence. 1. Has this persontestedpositivefor a controlledsubstancein the last threeyears? LIYES LINO 2. Has this personhad an alcoholtest with a BAC of .04 or greaterin the last three years? EYES flNO 3. Has this personrefuseda requiredtest for drugsor alcoholin the last three years? EYES ENO 4. Do you have knowledgethis personviolatedother DOT agencydrug and/oralcoholtestingregulations? EYES LINO 5. Have you receivedinformationfrom a previousemployerthis personviolatedDOT drug and alcoholregulations? EYES LINO lf yes to any of the above question,pleasegive the SAP contactinformation. PrintLastName Signature Date InformationReceivedby BaylorTruckingon (DATE)_l_l_BY REcEtvED By (cHEcKoNE) INFoRMATToN nrnx n unu lontine flTetephone notner | | TRUGKING 9269E STATEROAD48,MILAN,IN 47A31 X 570 800-322-9567 [email protected] FACSIMILE TRANSMITTAL SHEET TO: Recruiting FAX NUMBE R: 8 12-623-4622 F ROM: SE N D E R 'SP H ON EN U MBER: DATE: NUM BEROF PAGES: RE: INDEPENDENT CONTRACTOR APPLICATION DocumentChecklist n 2290paid and current tr Copy of title or applicationfor title -with owner's name n Powerof Attorneyif applicable n D.O.T.Inspectionlast 90 days n W-9 Form ! Scaleticket tr Registrationcab card-ifusing own plate ! IndependentContractorApplication Comments:
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