Driver’s Application For Employment

DRIVER'S APPLICATION FOR EMPLOYMENT

Step 1 of 13

7%

DRIVER'S APPLICATION FOR EMPLOYMENT
Applicant Name*
Date of Application*
Date Format: MM slash DD slash YYYY
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, veteran status, nor-job related disability, or any other protected group status.
TO BE READ AND SIGNED BY APPLICANT

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 connection with my application.

In the event of employment, I understand that false or misleading information given in my application or inter - view(s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the Company.

I understand that information I provide regarding current and/or previous employers may be used, and those employer(s) will be contacted, for the purpose of investigating my safety performance history as required by 49 CFR 391.23(d) and (e). I understand that I have the right to:
• Review information provided by previous employers;
• Have errors in the information corrected by previous employers and for those previous employers to re-send the corrected information to the prospective employer; and
• Have a rebuttal statement attached to the alleged erroneous information, if the previous employer(s) and I cannot agree on the accuracy of the information.
Signature*
Date*
Date Format: MM slash DD slash YYYY

APPLICANT TO COMPLETE
Position(s) Applied for*
Social Security No.*
Name*
First Middle Last
List your addresses of residency for the past 3 years.
Current Address*
Street Address City State / Province / Region ZIP / Postal Code Country
How Long?*
Do you have a previous address?*
- Yes
- No
Previous Address #1*
Street Address City State / Province / Region ZIP / Postal Code Country
How Long?*
Enter next previous address?*
- Yes
- No
Previous Address #2*
Street Address City State / Province / Region ZIP / Postal Code Country
How Long?*
Enter next previous address?*
- Yes
- No
Previous Address #3*
Street Address City State / Province / Region ZIP / Postal Code Country
How Long?*
Do you have the legal right to work in the United States?*
- Yes
- No
Date of Birth*
Date Format: MM slash DD slash YYYY

(Required for Commercial Drivers)
Can you provide proof of age?*
- Yes
- No
Have you worked for this company before?*
- Yes
- No
Where?*
From*
Date Format: MM slash DD slash YYYY
To*
Date Format: MM slash DD slash YYYY
Rate of Pay*
Position*
Reason for leaving*
Are you now employed?*
- Yes
- No
If not, how long since leaving last employment?*
Who referred you?*
Rate of pay expected*
Have you ever been bonded?*
- Yes
- No
(Answer only if a job requirement)
Name of bonding company*
Have you ever been convicted of a felony?*
- Yes
- No
If yes, please explain fully. Conviction of a crime is not an automatic bar to employment -alt circumstances will be considered.*
Is there any reason you might be unable to perform the functions of the job for which you have applied (explain if you wish)?*

EMPLOYMENT HISTORY

All driver applicants to drive in interstate commerce must provide the following information on all employers during the preceding 3 years. List complete mailing address, street number, city, state and zip code.

Applicants to drive a commercial motor vehicle* in intrastate or interstate commerce shall also provide an additional 7 years' information on those employers for whom the applicant operated such vehicle. (NOTE: List employers in reverse order starting with the most recent. Add another sheet as necessary.)

*Includes vehicles having a GVWR of 26,001 lbs. or more, vehicles designed to transport 16 or more passengers (including the driver), or any size vehicle used to transport hazardous materials in a quantity requiring placarding.
Employer #1 Name*
From*
Date Format: MM slash DD slash YYYY
To*
Date Format: MM slash DD slash YYYY
Position Held*
Salary / Wage*
Reason for leaving?*
Address*
Street Address City State / Province / Region ZIP / Postal Code Country
Contact Person*
Phone Number*
WERE YOU SUBJECT TO THE FMCSRs* WHILE EMPLOYED?*
- Yes
- No
*The Federal Motor Carrier Safety Regulations (FMCSRs) apply to anyone operating a motor vehicle on a highway in interstate commerce to transport passengers or property when the vehicle: (1) weighs or has a GVWR of 10,001 pounds or more, (2) is designed or used to transport more than 8 passengers (including the driver), OR (3) is of any size and is used to transport hazardous materials in a quantity requiring placarding.
WAS YOUR JOB DESIGNATED AS A SAFETY-SENSITIVE FUNCTION IN ANY DOT-REGULATED MODE SUBJECT TO THE DRUG AND ALCOHOL TESTING REQUIREMENTS OF 49 CFR PART 40?*
- Yes
- No
Enter Next Employer?*
- Yes
- No
Employer #2 Name*
From*
Date Format: MM slash DD slash YYYY
To*
Date Format: MM slash DD slash YYYY
Position Held*
Salary / Wage*
Reason for leaving?*
Address*
Street Address City State / Province / Region ZIP / Postal Code Country
Contact Person*
Phone Number*
WERE YOU SUBJECT TO THE FMCSRs* WHILE EMPLOYED?*
- Yes
- No
*The Federal Motor Carrier Safety Regulations (FMCSRs) apply to anyone operating a motor vehicle on a highway in interstate commerce to transport passengers or property when the vehicle: (1) weighs or has a GVWR of 10,001 pounds or more, (2) is designed or used to transport more than 8 passengers (including the driver), OR (3) is of any size and is used to transport hazardous materials in a quantity requiring placarding.
WAS YOUR JOB DESIGNATED AS A SAFETY-SENSITIVE FUNCTION IN ANY DOT-REGULATED MODE SUBJECT TO THE DRUG AND ALCOHOL TESTING REQUIREMENTS OF 49 CFR PART 40?*
- Yes
- No
Enter Next Employer?*
- Yes
- No
Employer #3 Name*
From*
Date Format: MM slash DD slash YYYY
To*
Date Format: MM slash DD slash YYYY
Position Held*
Salary / Wage*
Reason for leaving?*
Address*
Street Address City State / Province / Region ZIP / Postal Code Country
Contact Person*
Phone Number*
WERE YOU SUBJECT TO THE FMCSRs* WHILE EMPLOYED?*
- Yes
- No
*The Federal Motor Carrier Safety Regulations (FMCSRs) apply to anyone operating a motor vehicle on a highway in interstate commerce to transport passengers or property when the vehicle: (1) weighs or has a GVWR of 10,001 pounds or more, (2) is designed or used to transport more than 8 passengers (including the driver), OR (3) is of any size and is used to transport hazardous materials in a quantity requiring placarding.
WAS YOUR JOB DESIGNATED AS A SAFETY-SENSITIVE FUNCTION IN ANY DOT-REGULATED MODE SUBJECT TO THE DRUG AND ALCOHOL TESTING REQUIREMENTS OF 49 CFR PART 40?*
- Yes
- No
Enter Next Employer?*
- Yes
- No
Employer #4 Name*
From*
Date Format: MM slash DD slash YYYY
To*
Date Format: MM slash DD slash YYYY
Position Held*
Salary / Wage*
Reason for leaving?*
Address*
Street Address City State / Province / Region ZIP / Postal Code Country
Contact Person*
Phone Number*
WERE YOU SUBJECT TO THE FMCSRs* WHILE EMPLOYED?*
- Yes
- No
*The Federal Motor Carrier Safety Regulations (FMCSRs) apply to anyone operating a motor vehicle on a highway in interstate commerce to transport passengers or property when the vehicle: (1) weighs or has a GVWR of 10,001 pounds or more, (2) is designed or used to transport more than 8 passengers (including the driver), OR (3) is of any size and is used to transport hazardous materials in a quantity requiring placarding.
WAS YOUR JOB DESIGNATED AS A SAFETY-SENSITIVE FUNCTION IN ANY DOT-REGULATED MODE SUBJECT TO THE DRUG AND ALCOHOL TESTING REQUIREMENTS OF 49 CFR PART 40?*
- Yes
- No
Enter Next Employer?*
- Yes
- No
Employer #5 Name*
From*
Date Format: MM slash DD slash YYYY
To*
Date Format: MM slash DD slash YYYY
Position Held*
Salary / Wage*
Address*
Street Address City State / Province / Region ZIP / Postal Code Country
Reason for leaving?*
Contact Person*
Phone Number*
WERE YOU SUBJECT TO THE FMCSRs* WHILE EMPLOYED?*
- Yes
- No
*The Federal Motor Carrier Safety Regulations (FMCSRs) apply to anyone operating a motor vehicle on a highway in interstate commerce to transport passengers or property when the vehicle: (1) weighs or has a GVWR of 10,001 pounds or more, (2) is designed or used to transport more than 8 passengers (including the driver), OR (3) is of any size and is used to transport hazardous materials in a quantity requiring placarding.
WAS YOUR JOB DESIGNATED AS A SAFETY-SENSITIVE FUNCTION IN ANY DOT-REGULATED MODE SUBJECT TO THE DRUG AND ALCOHOL TESTING REQUIREMENTS OF 49 CFR PART 40?*
- Yes
- No
Enter Next Employer?*
- Yes
- No
Employer #6 Name*
From*
Date Format: MM slash DD slash YYYY
To*
Date Format: MM slash DD slash YYYY
Position Held*
Salary / Wage*
Address*
Street Address City State / Province / Region ZIP / Postal Code Country
Reason for leaving?*
Contact Person*
Phone Number*
WERE YOU SUBJECT TO THE FMCSRs* WHILE EMPLOYED?*
- Yes
- No
*The Federal Motor Carrier Safety Regulations (FMCSRs) apply to anyone operating a motor vehicle on a highway in interstate commerce to transport passengers or property when the vehicle: (1) weighs or has a GVWR of 10,001 pounds or more, (2) is designed or used to transport more than 8 passengers (including the driver), OR (3) is of any size and is used to transport hazardous materials in a quantity requiring placarding.
WAS YOUR JOB DESIGNATED AS A SAFETY-SENSITIVE FUNCTION IN ANY DOT-REGULATED MODE SUBJECT TO THE DRUG AND ALCOHOL TESTING REQUIREMENTS OF 49 CFR PART 40?*
- Yes
- No

ACCIDENT RECORD FOR PAST 3 YEARS OR MORE.
IF NONE, WRITE NONE*
Date Nature of Accident (Head-on, Rear-end, Upset, etc) Fatalities Injuries Hazardous Material Spill
TRAFFIC CONVICTIONS AND FORFEITURES FOR THE PAST 3 YEARS (OTHER THAN PARKING VIOLATIONS)
IF NONE, WRITE NONE*
Location Date Charge Penalty
EXPERIENCE AND QUALIFICATIONS - DRIVER
List all driver licenses or permits held in the past 3 years.
IF NONE, WRITE NONE*
State License No. Type Expiration Date
Have you ever been denied a license, permit or privilege to operate a motor vehicle?*
- Yes
- No
Give Details*
Has any license, permit or privilege ever been suspended or revoked?*
- Yes
- No
Give Details*
EXPERIENCE AND QUALIFICATIONS - DRIVER
List all driver licenses or permits held in the past 3 years.
Straight truck*
- Yes
- No
Type of equipment*
- Van
- Tank
- Flat
- Dump
- Refer
From*
Date Format: MM slash DD slash YYYY
To*
Date Format: MM slash DD slash YYYY
Approx. No. of Miles (Total)*
Tractor and Semi-Trailer*
- Yes
- No
Type of equipment*
- Van
- Tank
- Flat
- Dump
- Refer
From*
Date Format: MM slash DD slash YYYY
To*
Date Format: MM slash DD slash YYYY
Approx. No. of Miles (Total)*
Tractor - Two Trailers*
- Yes
- No
Type of equipment*
- Van
- Tank
- Flat
- Dump
- Refer
From*
Date Format: MM slash DD slash YYYY
To*
Date Format: MM slash DD slash YYYY
Approx. No. of Miles (Total)*
Tractor - Three Trailers*
- Yes
- No
Type of equipment*
- Van
- Tank
- Flat
- Dump
- Refer
From*
Date Format: MM slash DD slash YYYY
To*
Date Format: MM slash DD slash YYYY
Approx. No. of Miles (Total)*
Motorcoach - School Bus*
- Yes
- No
More than 8 passengers
From*
Date Format: MM slash DD slash YYYY
To*
Date Format: MM slash DD slash YYYY
Approx. No. of Miles (Total)*
Motorcoach - School Bus*
- Yes
- No
More than 15 passengers
From*
Date Format: MM slash DD slash YYYY
To*
Date Format: MM slash DD slash YYYY
Approx. No. of Miles (Total)*
Other*
- Yes
- No
Equipment Type*
From*
Date Format: MM slash DD slash YYYY
To*
Date Format: MM slash DD slash YYYY
Approx. No. of Miles (Total)*
List states operated in for last five years*
Show special courses or training that will help you as a driver*
Which safe driving awards do you hold and from whom?*
EXPERIENCE AND QUALIFICATIONS - OTHER
SHOW ANY TRUCKING, TRANSPORTATION OR OTHER EXPERIENCE THAT MAY HELP IN YOUR WORK FOR THIS COMPANY*
LIST COURSES AND TRAINING OTHER THAN SHOWN ELSEWHERE IN THIS APPLICATION*
LIST SPECIAL EQUIPMENT OR TECHNICAL MATERIALS YOU CAN WORK WITH (OTHER THAN THOSE ALREADY SHOWN)*
EDUCATION
HIGHEST GRADE COMPLETED*
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
HIGH SCHOOL*
- 1
- 2
- 3
- 4
COLLEGE*
- 1
- 2
- 3
- 4
TO BE READ AND SIGNED BY 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.
Signature*
Date*
Date Format: MM slash DD slash YYYY

MOTOR VEHICLE DRIVER'S Certification of Violations/Annual Review of Driving Record
MOTOR CARRIER INSTRUCTIONS: Each motor carrier shalt at least once every 12 months, require each driver it employs to prepare and furnish it with a list of all violations of motor vehicle traffic laws and ordinances (other than violations involving only parking) of which the driver has been convicted, or on account of which he/she has forfeited bond or collateral during the preceding 12 months (Section 391.27). Drivers who have provided information required by Section 353.31 need not repeat that information on this form.

DRIVER REQUIREMENTS: Each driver shall furnish the list as required by the motor carrier above. If the driver has not been convicted of, or forfeited bond or collateral on account of any violation which must be listed, he/she shall so certify (Section 391.27).

COMPLETED BY DRIVER - CERTIFICATION OF VIOLATIONS
Name of Driver*
Social Security Number*
Date of Employment*
Date Format: MM slash DD slash YYYY
Home Terminal (City and State)*
Driver's License Number*
State*
Expiration Date*
Date Format: MM slash DD slash YYYY
I certify that the following is a true and complete list of traffic violations required to be listed (other than those I have provided under Part 383) for which I have been convicted or forfeited bond or collateral during the past 12 months.
(If you have had no violations, write "None")*
Date Offense Location Type of Vehicle Operated
If no violations are listed above, I certify that I have not been convicted or forfeited bond or collateral on account of any violation (other than those I have provided under Part 383) required to be listed during the past 12 months.
Date of Certification*
Date Format: MM slash DD slash YYYY
Driver's Signature*

DRIVER CERTIFICATION FOR OTHER COMPENSATED WORK
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 paragraphs (8) and (9) of the Federal Motor Carrier Safety 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 nonmotor carrier entity.
Are you currently working for another employer?*
- Yes
- No
At this time do you intend to work for another employer while still employed by 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(s) for compensation that I must inform this company immediately of such employment activity.
Driver's Signature*
Date*
Date Format: MM slash DD slash YYYY

PREVIOUS PRE-EMPLOYMENT EMPLOYEE ALCOHOL AND DRUG TEST STATEMENT
See. 40.25(j) As the employer, you must also ask the employee whether he or she has tested positive, or refused to test, on any pre-employment drug or alcohol test administered by an employer to which the employee applied for, but did not obtain, safety-sensitive transportation work covered by DOT agency drug and alcohol testing rules during the past two years. If the employee admits that he or she had a positive test or a refusal to test, you must not use the employee to perform safety-sensitive functions for you, until and unless the employee documents successful completion of the return-to-duty process. (see Sec. 40.25(b)(5) and (e))
Prospective Employee Name*
ID Number*
The prospective employee is required by Sec. 40.250) to respond to the following questions.

1) Have you tested positive, or refused to test, on any pre-employment drug or alcohol test administered by an employer to which you applied for, but did not obtain, safety sensitive transportation work covered by DOT agency drug and alcohol testing rules during the past two years?
Check one*
- Yes
- No
2) If you answered yes, can you provide/obtain proof that you've successfully completed the DOT return-to-duty requirements?
Check one*
- Yes
- No
I certify that the information provided on this document is true and correct.
Prospective Employee Signature*
Date*
Date Format: MM slash DD slash YYYY
Millennium Trucking, Inc.
Substance Abuse Policy

In 1988, Congress enacted the Drug Free Workplace Act to require federal contractors to establish and maintain a work environment that is free from the effects of drug use and abuse. Federal regulations present the general terms of this program and its guidelines. We agree with the goal and believe that our Company has responsibility to its employees and those who use or come in contact with its products/services, to ensure a safe and productive work environment. To satisfy these responsibilities, it is the policy of this Company and a condition of employment that an employee be present and able to perform their job free from the effects of alcohol, narcotics, depressants, stimulants, hallucinogens and cannabis or any other substances, which can impair job performance.

Our Commitment
We recognize that drug and alcohol abuse may be a sign of chemical dependency and that substance abuse can be successfully treated with professional help.

Our company provides information to the driver for an Employee Assistance Program (EAP) through saplist.com for employees to deal with substance abuse and other personal problems that can affect work performance. Our commitment is to help employees remain productive members of our team. In certain circumstances, the company may insist upon a mandatory referral to our EAP as a condition of continued employment. No employee will be disciplined or discriminated against simply for asking for help.

Employee Responsibility
The employee is responsible for following all of our work and safety rules, and for observing the standards of behavior and employer, co-workers, and customers have the right to expect from you. In addition if you believe you may have a problem with drugs or alcohol, you are responsible for seeking assistance, whether from or through the company or any other resource, before the drug or alcohol problem adversely affects your work performance or results in a violation of this policy. The time to seek help is before you are in "trouble", NOT AFTER. If a professional assessment is made that you have a problem with Drugs or Alcohol, your continued employment is conditioned upon: • Entering into and completing a treatment program approved by the company. • Signing and living up to a last chance performance agreement. • Undergoing a Follow-up Testing Program at company's direction.

Scope of Our Policy
This policy and each of its rules apply whenever an employee is on or in Company Property, surrounding grounds and parking lots, leased or rented space. Company time (including breaks and meal periods), in any vehicle used on Company business, and in other circumstances (such as on customer premises or at business/sales functions) we believe may adversely affect our operations, safety or the administration of this policy.

Our Drug and Alcohol Rules
The following rules are extremely important and an employee who violates any one of them will be subject to disciplinary action, up to and including termination.

1. Alcohol. An employee may not possess, use, transfer, offer, or be under the influence of any intoxicating liquor while at work or on company business. This rule prohibits using any alcohol prior to reporting to work, during breaks or meal periods, or in conjunction with any Company activity, except social or business events where a Corporate Officer has authorized the moderate consumption of Alcoholic Beverages.

2. An employee will be removed from Safety Sensitive Position for 24 hours if your BA is more than .02 and less than .04. A Breath Test over .04 is a DOT Violation, and a referral will be required to a Substance Abuse Professional before being released back to a safety sensitive position.

3. Drugs. An Employee may not possess, use, transfer, offer, share, attempt to sell or obtain, manufacture, or be under the influence of any drug or similar substance and also may not have any drugs of similar substances present in the body. Thus, employees who test positive for any illegal drug violates this rule is a DOT Violation and a referral will be required to a Substance Abuse Professional before being released back to a safety sensitive position. This rule also pertains to Prescription drugs being taken without doctor's authorization.

4. Drug Paraphernalia Alcohol Containers. An employee may not possess any Drug Paraphernalia or Alcohol Containers.

5. Prescriptions/Over the counter Medications. It is the employee's responsibility to check the potential effects of prescribed drugs and over the counter Medications with your doctor or pharmacists before starting work, and to immediately let you supervisor know when such use makes it unsafe for you to report to work or do your job.

6. Adulterants. Any substance that is used for the purpose of manipulating a drug test by adding to the specimen or ingesting.

Reasonable Suspicion Testing or Reasonable Cause
At least one Supervisor will be trained in accordance to DOT to make these observations of Work Performance, Behavior and Physical Indicators.
• Observable Symptoms or Unusual Behavior
• The Odor or Smell of Alcohol or Drugs on the employees breath or clothes or in an area (such as in a vehicle, office, work area, or restroom) immediately controlled or occupied by the employee.
• Alcohol, alcohol containers, illegal drugs or drug paraphernalia in the employee's possession or in an area controlled or occupied by the employee (vehicle, office, desk restroom);
• Unexplained or significant deterioration in job performance.
• Unexplained significant changes in behavior (e.g., abusive behavior, repeated disregard of safety rules or procedures, insubordination, etc.);
• Evidence that the employee may have tampered with a previous drug test.
• Criminal citations, arrests or convictions involving drugs and alcohol.
• Unexplained absenteeism or tardiness.
• Employee admissions regarding drug or alcohol use;
• Any involvement in any work related accident or near misses.
• Any type of Paraphernalia discover on your person or Company Property.

Fit for Duty
The Company could require a fit for duty exam by a certified Medical Practitioner; this exam can be administered along with Drug and Alcohol Screen to determine if employee is fit for Duty. This could be requested in addition to the DOT Medical card Certificate.

Duty to Cooperate
An employee who fails to cooperate in the administration of this policy generally will be terminated. This includes such things as:
• Refusing to consent to testing, to submit a sample, or to sign required forms.
• Refusing to cooperate in any way (for example refusing to courteously and candidly cooperate in any interview or investigation, including any form of truthfulness, misrepresentation or misleading statements or omissions);
• Any form of dishonesty in the investigation or testing process.
• Refusing to test again at a time of the Company's choosing whenever any test results in a finding of a dilute sample.
• Testing dilute on any requested retest after an initial dilute result: and
• Failure to accept the referral, to enter into and complete an approved treatment program, or to sign or adhere to the commitments in the Last Chance Performance Agreement.

Pre-Employment Testing
All safety sensitive employees are required to pass a DOT pre-employment urine drug test before being hired and or driver any Commercial Motor Vehicle.

Random Testing Program
The Random-testing program is implemented by a third party and/or computerized Selection Process thru out the year. The Third Party Administrator (TPA) combines the employees from our company with employees from other companies. The TPA selects 4 times per year and notifies the DER, Designated Employee Representative. The DER can notify the Employee within the selection period. When the employee is notified, they must test ASAP. DOT does not allow testing delays due to convenience.

Mandatory Post Accident Testing
Post accident drug and/or alcohol testing will be at supervisor or company request.

See Chart

Type of accident involved	Citation issued to the CMV driver? (Class A_or_B)	Test must be Performed
Human Fatality	Yes No	Yes Yes
Bodily injury with immediate medical treatment away from the scene	Yes No	Yes No
Disabling damage to any motor vehicle requiring tow away	Yes No	Yes No

EMPLOYEE ACKNOWLEDGEMENT AND CONSENT TO TESTING

I acknowledge receiving a copy of the Company's Drug and Alcohol Policy.

I voluntarily agree to provide a sample of my Urine for Testing and to submit to any related physical or other examination when I have been requested to do so.

I authorize the release of the test result (and any other relevant medical information) to the company for its use evaluation and suitability for continued employment. I also release the Company from all liability arising out of or connected with testing.

I understand that if I refuse to submit to the testing, to give a requested sample(s), to authorize release of the results to the company, and/or if the test results indicate that I do not meet the Company's standards, I may be terminated.

I understand that any attempt to switch, adulterate or in any way tamper with the requested sample(s) or to other wise manipulate the testing process will result in termination of employment.
Driver Signature*
Date*
Date Format: MM slash DD slash YYYY

THE BELOW DISCLOSURE AND AUTHORIZATION LANGUAGE IS FOR MANDATORY USE BY ALL ACCOUNT HOLDERS
IMPORTANT DISCLOSURE REGARDING BACKGROUND REPORTS FROM THE PSP Online Service

In connection with your application for employment with Millennium Trucking, Inc. ( Prospective Employer"), Prospective Employer, its employees, agents or contractors may obtain one or more reports regarding your driving, and safety inspection history from the Federal Motor Carrier Safety Administration (FMCSA).

When the application for employment is submitted in person, if the Prospective Employer uses any information it obtains from FMCSA in a decision to not hire you or to make any other adverse employment decision regarding you, the Prospective Employer will provide you with a copy of the report upon which its decision was based and a written summary of your rights under the Fair Credit Reporting Act before taking any final adverse action. If any final adverse action is taken against you based upon your driving history or safety report, the Prospective Employer will notify you that the action has been taken and that the action was based in part or in whole on this report.

When the application for employment is submitted by mail, telephone, computer, or other similar means, if the Prospective Employer uses any information it obtains from FMCSA in a decision to not hire you or to make any other adverse employment decision regarding you, the Prospective Employer must provide you within three business days of taking adverse action oral, written or electronic notification: that adverse action has been taken based in whole or in part on information obtained from FMCSA; the name, address, and the toll free telephone number ofFMCSA; that the FMCSA did not make the decision to take the adverse action and is unable to provide you the specific reasons why the adverse action was taken; and that you may, upon providing proper identification, request a free copy of the report and may dispute with the FMCSA the accuracy or completeness of any information or report. If you request a copy of a driver record from the Prospective Employer who procured the report, then, within 3 business days of receiving your request, together with proper identification, the Prospective Employer must send or provide to you a copy of your report and a summary of your rights under the Fair Credit Reporting Act.

Neither the Prospective Employer nor the FMCSA contractor supplying the crash and safety information has the capability to correct any safety data that appears to be incorrect. You may challenge the accuracy of the data by submitting a request to https:/fdataqs.fmcsa.dot.gov . If you challenge crash or inspection information reported by a State, FMCSA cannot change or correct this data. Your request will be forwarded by the DataQs system to the appropriate State for adjudication.

Any crash or inspection in which you were involved will display on your PSP report. Since the PSP report does not report, or assign, or imply fault, it will include all Commercial Motor Vehicle (CMV) crashes where you were a driver or co-driver and where those crashes were reported to FMCSA, regardless of fault. Similarly, all inspections, with or without violations, appear on the PSP report. State citations associated with Federal Motor Carrier Safety Regulations (FMCSR) violations that have been adjudicated by a court of law will also appear, and remain, on a PSP report.

The Prospective Employer cannot obtain background reports from FMCSA without your authorization.

AUTHORIZATION

If you agree that the Prospective Employer may obtain such background reports, please read the following and sign below: Millennium Trucking, Inc. I authorize ("Prospective Employee) to access the FMCSA Pre-Employment Screening Program (PSP) system to seek information regarding my commercial driving safety record and information regarding my safety inspection history. I understand that I am authorizing the release of safety performance information including crash data from the previous five (5) years and inspection history from the previous three (3) years. I understand and acknowledge that this release of information may assist the Prospective Employer to make a determination regarding my suitability as an employee.

I further understand that neither the Prospective Employer nor the FMCSA contractor supplying the crash and safety information has the capability to correct any safety data that appears to be incorrect. I understand I may challenge the accuracy of the data by submitting a request to https://dataqs.fmcsa.dot.gov . If! challenge crash or inspection information reported by a State, FMCSA cannot change or correct this data. I understand my request will be forwarded by the DataQs system to the appropriate State for adjudication.

I understand that any crash or inspection in which I was involved will display on my PSP report. Since the PSP report does not report, or assign, or imply fault, I acknowledge it will include all CMV crashes where I was a driver or co-driver and where those crashes were reported to FMCSA, regardless of fault. Similarly, I understand all inspections, with or without violations, will appear on my PSP report, and State citations associated with FMCSR violations that have been adjudicated by a court of law will also appear, and remain, on my PSP report.

I have read the above Disclosure Regarding Background Reports provided to me by Prospective Employer and I understand that if I sign this Disclosure and Authorization, Prospective Employer may obtain a report of my crash and inspection history. I hereby authorize Prospective Employer and its employees, authorized agents, and/or affiliates to obtain the information authorized above.
Signature*
Date*
Date Format: MM slash DD slash YYYY
NOTICE: This form is made available to monthly account holders by NIC on behalf of the U.S. Department of Transportation, Federal Motor Carrier Safety Administration (FMCSA). Account holders are required by federal law to obtain an Applicant's written or electronic consent prior to accessing the Applicant's PSP report. Further, account holders are required by FMCSA to use the language contained in this Disclosure and Authorization form to obtain an Applicant's consent. The language must be used in whole, exactly as provided. Further, the language on this form must exist as one stand-alone document. The language may NOT be included with other consent forms or any other language.

NOTICE: The prospective employment concept referenced in this form contemplates the definition of "employee" contained at 49 C.F.R. 383,5.

AUTHORIZATION TO OBTAIN CONSUMER AND/OR INVESTIGATIVE CONSUMER REPORT
I have carefully read, and understand this Authorization form. I further acknowledge receipt of the "Disclosure Regarding Consumer and/or Investigative Consumer Report" and "State Law Notices" and certify that I have read and understand both documents. I understand that Company may obtain a consumer report and/or investigative consumer report for employment purposes, in connection with a business transaction initiated by you, or otherwise upon your written instructions. These reports may be obtained at any time after receipt of my authorization, and if I am hired or engaged to transact business with the Company, throughout my employment or relationship with the Company. I understand that the Company reserves the right to share the information contained in the report(s) with any third-party companies for whom I will be placed to work or with whom I will have a relationship or will have access to the premises. My information will only be used and/or disclosed as permitted by law and as required for creation of any report(s).
I understand and authorize information which is contained in my employment application, or otherwise disclosed by me, may be used for the purpose of obtaining consumer reports and/or investigative background reports at any time during my relationship with the Company. I also understand that nothing herein shall be construed as an offer of employment. I hereby authorize law enforcement agencies, educational institutions (including public and private schools/universities), information service bureaus, drug laboratories, consumer reporting agencies, record/data repositories, courts (federal, state, and local), motor vehicle records agencies, my past or present employers, the military, and other information sources to furnish any, and all, information on me that is requested by eVenfile.

A credit report may be obtained in connection with your application for employment. If a credit report has been ordered, you may have additional rights under the Federal and State laws. If Company orders a credit report it will be for the following reason:

California Applicants Only: I acknowledge receipt of a copy of California Civil Code 1786.22. Pursuant to Section 1786.22 of the California Civil Code, you may view the file maintained on you by eVerifile during normal business hours. You may also obtain a copy of this file, upon submitting proper identification by appearing at eVenfiles offices in person, during normal business hours and on reasonable notice, or by mail. You may also receive a summary of the file by telephone, upon submitting proper identification. eVenfile has trained personnel available to explain your file to you, including any coded information. By signing below, you acknowledge receipt of California Civil Code 1786.22.
New York Applicants Only: I acknowledge receipt of a copy of Article 23-A of New York Correction Law. By signing below, you acknowledge receipt of Article 23-A of the New York Correction Law.

California, Minnesota or Oklahoma applicants only:
You may receive a free copy of any consumer report or investigative consumer report obtained on you if you check the box below.
- I wish to receive a free copy of the report
I HEREBY CERTIFY THAT THIS FORM WAS COMPLETED BY ME, THAT THE INFORMATION PROVIDED IS TRUE AND CORRECT AS OF THE DATE HEREOF AND I AUTHORIZE E-VERIFILE TO OBTAIN A CONSUMER REPORT AND/OR INVESTIGATIVE CONSUMER REPORT ON ME, AS APPLICABLE I acknowledge that the Company has provided me with a copy of A Summary of Your Rights Under the Fair Credit Reporting Act.
Signature*
Date*
Date Format: MM slash DD slash YYYY
Name*
First Middle Last
Social Security Number*
Gender*
- Male
- Female
DOB*
Date Format: MM slash DD slash YYYY
Driver's License #*
Issuing State*
Daytime Phone Number*
Email Address*
Enter Email Confirm Email
Other Names Used (alias, maiden, nickname)*
Current Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Motor Vehicle Driver's CERTIFICATION OF COMPLIANCE WITH DRIVER LICENSE REQUIREMENTS
MOTOR CARRIER INSTRUCTIONS: The requirements in Part 383 apply to every driver who operates in intrastate, interstate, or foreign commerce and operates a vehicle weighing 26,001 pounds or more, can transport more than 15 people, or transports hazardous materials that require placarding.

The requirements in Part 391 apply to every driver who operates in interstate commerce and operates a vehicle weighing 10,001 pounds or more, can transport more than 15 people, or transports hazardous materials that require placarding.

DRIVER REQUIREMENTS: Parts 383 and 391 of the Federal Motor Carrier Safety Regulations contain some requirements that you as a driver must comply with. They are as follows:

1) POSSESS ONLY ONE LICENSE: You, as a commercial vehicle driver, may not possess more than one motor vehicle operator's license.

2) NOTIFICATION OF LICENSE SUSPENSION, REVOCATION OR CANCELLATION: Sections 391.15(b)(2) and 363.33 of the Federal Motor Carrier Safety Regulations require that you notify your employer the NEXT BUSINESS DAY of any revocation or suspension of your driver's license. In addition, Section 383.31 requires that any time you are convicted of violating a state or local traffic law (other than parking), you must report it within 30 days to: 1) your employing motor carrier, and 2) the state that issued your license (if the violation occurs in a state other than the one which issued your license). The notification to both the employer and state must be in writing.

3) CDL DOMICILE REQUIREMENT: Section 383.23(a)(2) requires that your commercial driver's license be issued by your legal state of domicile, where you have your true, fixed, and permanent home and principal residence and to which you have the intention of returning whenever you are absent. If you establish a new domicile in another state, you must apply to transfer your CDL within 30 days.

The following license is the only one I possess:
Driver's License No.*
State*
Exp. Date*
Date Format: MM slash DD slash YYYY
DRIVER CERTIFICATION: I certify that I have read and understood the above requirements.
Driver's Signature*
Date*
Date Format: MM slash DD slash YYYY
Notes

CERTIFICATE OF COMPLIANCE WITH CELL-PHONE/TEXTING BANS

MOTOR CARRIERS: The restrictions in 49 CFR Part 392 on using a mobile telephone or texting while driving apply to every operator of a "commercial motor vehicle" as defined in Section 390.5, including interstate vehicles weighing or rated at 10,001 pounds or more, vehicle placarded for hazardous materials, and certain vehicles designed or used for more than 8 passengers (including the driver). In-state operations of vehides placarded for hazardous materials are also subject to the restrictions. Other In-state-only operations may also be subject, depending on state rules.

DRIVERS: Part 392 of the Federal Motor Carrier Safety Regulations (FMCSR) contain restrictions on texting and the use of hand-held mobile telephones while driving a commercial motor vehicle (CMV), including the following:

1. Textlng ban (392.80): You may not manually enter text into or read text from an electronic device while driving a CMV. This includes e-mailing, text messaging, using the Internet, pressing more than one button to start or end a phone call, or any other form of text retrieval or entry for communication devices.
2. Hand-held cell-phone ban (392.82): You are prohibited from using a hand-held phone while driving a CMV. This includes talking on a phone while holding it in your hand (including push-to-talk), pressing more than a single button to dial or answer a cell phone, or leaving your normal, seated driving position to reach for a cell phone.

Except as prohibited under company policy, you are allowed to use a hands-free phone, a CB radio, a navigation system, a two-way radio, a music player, or a fleet management system for purposes other than texting. Texting and hand-held cell-phone use are only allowed if you need to contact emergency services or if you have stopped in a safe location off the road.

Penalties (383.51, 391.15): CDL and non-CDL drivers can be disqualified for 60 days up to 120 days and/or face fines up to $2,750 for each violation.

DRIVER CERTIFICATION: I certify that I have read and understand the above violation.
Driver's Signature*
Date*
Date Format: MM slash DD slash YYYY

Millenniun Trucking, Inc. No Rider Policy

Overview

Driver safety is very important to Millennium Trucking, Inc., and we recognize the importance of famy and friends in a driver's life and the support they provide to our drivers.

Policy

No driver shall transport any person or permit any person to be transported on a company vehicle, nor shaft they be permitted to board the vehicle pursuant to company policy.

Due to insurance requirements, only those qualified and authorized will be allowed to operate or be transported in equipment owned by or leased with Millennium Trucking, Inc.

Failure to comply with this policy will result in disciplinary action up to and including termination of employment or contract.
Driver's Signature*
Date*
Date Format: MM slash DD slash YYYY
CAPTCHA
Phone
This field is for validation purposes and should be left unchanged.

Atlanta – Main Office

connect

CONTACT

Phone: 770-817-1790

Fax: 770-817-1785

370 Six Flags Parkway
Mableton, GA 30126

info@millenniumfreight.com

Home
About
Trucking
Brokerage
Agents
Customers
JOBS
Contact

Date	Nature of Accident (Head-on, Rear-end, Upset, etc)	Fatalities	Injuries	Hazardous Material Spill

Location	Date	Charge	Penalty

State	License No.	Type	Expiration Date

Date	Offense	Location	Type of Vehicle Operated