RETURN THIS FORM BY: EMAIL: [email protected] FAX: 618-219-4186 MAIL: 22 Gateway Commerce Center. W Ste 100 Edwardsville, IL 62025

The purpose of this application is to determine whether or not the applicant is qualified to operate motor carrier equipment according to the requirements of the Federal Motor Carrier Safety Regulations and the Company named above.

Instructions to Applicant

Please answer all questions. If the answer to any question is “No” or “None”, do not leave the item blank, but write “No” or “None”. This is important!

Application Date:
Position applying for; Check One:
Name:
Home Phone Number:
-
Mobile Phone Number:
-
Email Address:
Emergency Contact Information:
-
Age:
Date of Birth:
Social Security Number:
Driver's License Number
Driver's License State
* The Age Discrimination of Employment Act of 1967 prohibits discrimination on the basis of age with respect to individuals who areat least 40 years of age.
DOT Physical Expiration Date:
Current & Three Years Previous Addresses:
Address 1 (Street, City, State, Zip):
From:
To:
Address 2 (Street, City, State, Zip):
From:
To:
Address 3 (Street, City, State, Zip):
From:
To:
Have you worked for this company before?
If yes, give dates: From:
To:
Reason for Leaving?

Education History

Please circle the highest grade completed:
Grade School
College
Post Graduate

Employment History

You must include all employment for the past three years, allcommercial driving experience for previous 10 years and allunemployment or self-employment. No gaps between employment.
Mo/Yr
From:
To:
Position Held:
Reason For Leaving?
Were you subject to the FMCSRs* while employed here?
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?

Present or Last Employer:

Name:
Address (Street, City, State, Zip):
Phone:
-
Fax:
-
From:
To:
Position Held :
Reason For Leaving?
Were you subject to the FMCSRs* while employed here?
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?

Present or Last Employer:

Name:
Address (Street, City, State, Zip):
Phone:
-
Fax:
-
From:
To:
Position Held:
Were you subject to the FMCSRs* while employed here?
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?

Present or Last Employer:

Name:
Address (Street, City, State, Zip):
Phone:
-
Fax:
-
From:
To:
Position Held:
Reason For Leaving?
Were you subject to the FMCSRs* while employed here?
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?

Present or Last Employer:

Name:
Address (Street, City, State, Zip):
Phone:
-
Fax:
-
From:
To:
Position Held:
Reason For Leaving?
Were you subject to the FMCSRs* while employed here?
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?

Present or Last Employer:

Name:
Address (Street, City, State, Zip):
Phone:
-
Fax:
-
From:
To:
Position Held:
Reason For Leaving?
Were you subject to the FMCSRs* while employed here?
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?

Present or Last Employer:

Name:
Address (Street, City, State, Zip):
Phone:
-
Fax:
-
From:
To:
Position Held:
Reason For Leaving?
Were you subject to the FMCSRs* while employed here?
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? (1)

Present or Last Employer:

Name:
Address (Street, City, State, Zip):
Phone:
-
Fax:
-
From:
To:
Position Held:
Reason For Leaving?
Were you subject to the FMCSRs* while employed here?
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?

Present or Last Employer:

Name:
Address (Street, City, State, Zip):
Phone:
-
Fax:
-
From:
To:
Position Held:
Reason For Leaving?
Were you subject to the FMCSRs* while employed here?
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?

Present or Last Employer:

Name:
Address (Street, City, State, Zip):
Phone:
-
Fax:
-
From:
To:

Driving Experience

Class Of EquipmentFrom            To

          Total number of miles (approx.)

Straight Truck:

From:
To:
Total number of miles (approx.)

Tractor/Semi Trailer:

From
To
Total number of miles (approx.)

Straight Truck:

From
To
Total number of miles (approx.)
List states operated in for the last five years:
List special courses/training completed (PTD, DDC, HazMat, etc.):
List any Safe Driving Awards you hold and from whom:
Date Of AccidentNature of accidents (Head on, rear end, roll over, etc.)Location of Accident# of Fatalities# of injuries
Date Of Accident:
Nature of accidents
Location of Accident:
# of Fatalities
#of injuries

Traffic Convictions and Forfeitures for the last three years (other than parking violations)

DateLocationChargePenalty/Fine
Date1:
Location1:
Charge1:
Penalty1:
Date2:
Location2:
Charge2:
Penalty2:

Driver’s License (list each driver’s license held in the past three years)

StateLicense NumberTypeEndorsementExpiration Dat
A. Have you ever been denied a license, permit or privilege to operate a motor vehicle?.
B. Has any license, permit or privilege ever been suspended or revoked?.........................
C. Is there any reason you might be unable to perform the functions of the job for which you have applied (as described in the job description)?......................................
D. Have you ever been convicted of a felony?....................................................................
If the answer to A, B, C or D is “YES”, please explain

PERSONAL REFERENCES

List three persons for references, other than family members, who have knowledge of your safety habits.

Name:
Address (Street, City, State, Zip):
Phone:
-
Name:
Address (Street, City, State, Zip):
Phone:
-
Name:
Address (Street, City, State, Zip):
Phone:
-

To Be Read and Signed by Applicant

It is agreed and understood that any misrepresentations given on this application shall be considered an act of dishonesty.
It is agreed and understood that the motor carrier or his agents my investigate the applicant’s background to ascertain any and all
information of concern to applicant’s record, whether same is of record or not, and applicant releases employers and persons named
herein from all liability for any damages on account of his furnishing such information.
It is also agreed and understood that under the Fair Credit Reporting Act, Public Law 91-509, I have been told that this investigation
may include an investigating Consumer Report, including information regarding my character, general reputation, personal
characteristics, and mode of living.
I agree to furnish such additional information and complete such examinations as may be required to complete my application file.
It is agreed and understood that this Application for Qualification in no way obligates the motor carrier to employ or hire the
applicant.
It is agreed and understood that if qualified and hired, I may be on a probationary period during which time I may be disqualified
without recourse.
This certifies that this application was completed by me, and that all entries on it and information in it are true, correct and complete
to the best of my knowledge.

Date:
Remarks (for office use only)
REQUEST FOR DRIVER’S SAFETY PERFORMANCE HISTORYINFORMATION FROM DOT REGULATED PREVIOUS EMPLOYER(S)
As a Commercial Motor Vehicle (CMV) Driver, I understand that per the Federal Motor CarrierSafety Regulations (FMCSR's) Part 391.21, the following information will be requested from allprevious employers for which I operated a CMV, subject to FMCSR Parts 390 and/or 40, 382 &383, within the past three years, from date shown below. I also acknowledge that thisinformation will be used in determining my eligibility to be hired, that I have the right toreview this information and rebut any errors in these statements from my prior employers, asdescribed in the FMCSR Part 391.23.
I, (print name)
hereby authorize this company to release all records of employment, including assessments of my job performance, ability and fitness, including datesof any and all alcohol or drug tests. Those confirmed results and/or my refusal to submit to anyalcohol, or drug tests and any rehabilitation completion under direct of (SAP/MRO) toeach and every company (or their authorized agents) which may request such information inconnection with my application for employment with said company. I hereby release thiscompany, and it’s employees, officers, directors and agents from any and all liability of any typeas a result of providing information to the above‐mentioned person and/or company.
SSN:
DOB:
Today's Date:

DRIVER’S RIGHTS PERTAINING TO RELEASE OF DRIVERINFORMATION UNDER REGULATION 391.23

Motor carriers have the responsibility to make the following investigations and inquiries with respect to each driveremployed, other than a person who has been a regularly employed driver of the motor carrier for a continuous periodwhich began before January 1, 1971.
  • (a)(1) An inquiry into the driver’s driving record during the preceding three years to the appropriate agency ofevery State in which the driver held a motor vehicle operator’s license or permit during those three years; and
  • (a)(2) An investigation of the driver’s employment record during the preceding three years
  • (b) A copy of the driver record(s) obtained in response to the inquiry or inquiries to each State driver recordagency as required must be placed in the Driver Qualification File within 30 days of the date the driver’semployment begins and be retained in compliance with 391.51.
  • (c) Replies to the investigations of the driver’s safety performance history must be placed in the DriverInvestigation History File within 30 days of the date the driver’s employment begins. This goes into effect afterOctober 29, 2004.
  • (d) Prospective motor carrier must investigate the information from all previous employers of the applicant thatemployed the driver to operate a CMV within the previous three years. This information must cover generaldriver identification and employment verification information, data elements as specified in 390.15 for accidentinvolving the driver that occurred in the three-year period preceding the date of the employment application, andany accidents the previous employer may wish to provide.
  • (e) Prospective motor carrier must investigate the information from all previous DOT regulated employers thatemployed the driver within the previous three years from the date of the employment application in a safetysensitivefunction that required alcohol and controlled substance testing specified by 49 CFR Part 40.
Drivers have the following rights:
  1. The right to review information provided by previous employers.
  2. The right to have errors in the information corrected by the previous employer and for that previous employer tore-send the corrected information to the prospective employer.
  3. The right to have a rebuttal statement attached to the alleged erroneous information, if the previous employer andthe driver cannot agree on the accuracy of the information.
Drivers who wish to review previous employer-provided investigative information must submit a written request to theprospective employer when applying or as late as 30 days after employed or being notified of denial of employment.The prospective employer must provide this information to the applicant within five business days of receiving thewritten request. If the driver has not arranged to pick up or receive the requested records within 30 days of theprospective employer making them available, the prospective motor carrier may consider the driver to have waivedhis/her request to review the records

Drivers wishing to request correction of erroneous information in records must send the request for the correction to theprevious employer that provided the records. After October 29, 2004, the previous employer must either correct andforward the information to the prospective motor carrier employer or notify the driver within 15 days of receiving thedriver’s request to correct the data that it does not agree to correct the data. Drivers wishing to rebut information inrecords must send the rebuttal to the previous employer with instruction to include the rebuttal in the driver’s SafetyPerformance History.I acknowledge that I have read and understand the contents of this document
Driver Name (Printed):
Date:

DRIVER APPLICANT DRUG AND ALCOHOLPRE-EMPLOYMENT STATEMENT

CFR Part 40.25(j) requires the employer to ask any applicant, whether he or she has tested positive, or refused totest, 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 rules during thepast two years. If the potential employee admits that he or she had a positive test or refusal to test, we must not usethe employee to perform safety-sensitive functions, until and unless the potential employee provides documentationof successful completion of the return-to-duty process.(See Section 40.25(b)(5) and (e).
Applicant Name:(Please Print)
As an applicant, applying to perform safety-sensitive functions for our company, you are required by CFR Part40.25(j) 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?
2. If you answered yes, to the above question, can you provide proof that you have successfully completed the DOT return-to-duty requirements?
My signature below certifies that the information provided is true and correct.
Date:

CONTROLLED SUBSTANCE & ALCOHOL TESTINGINFORMATIONACKNOWLEDGEMENT/CONSENTFORM

As a condition of employment with BL Logistics LLC. (Motor Carrier), Commercial Motor Vehicle (CMV) DriverApplicants must submit to a pre-employment controlled substances test as required by the Federal Motor CarrierSafety Regulations (FMCSR) Section 382.301. A motor carrier must receive verified negative test results for theapplicant driver for the applicant to be eligible for employment.

If you are hired, you will be subject to laws requiring additional controlled substances and alcohol testing on you undernumerous situations including, but not limited to, the following:
Post-Accident – Section 382.303Random– Section 382.305Reasonable Suspicion – Section 382.307
Return to Duty – Section 382.309
Follow-up – Section 382.311


A driver who tests positive for a controlled substance(s) and/or alcohol test, will be immediately removed from a safetysensitive position as required by Part 382 of the FMCSR. Federal law prohibits a driver from returning to a safetysensitive position for any motor carrier until and unless the driver completes the Substance Abuse Professionals (SAP) evaluation, referral and educational/treatment process, as described in FMCSR Part 40, Subpart O.



The following is a referral list of Substance Abuse Professionals: (to be completed by Carrier)

NAMENeela WilliamsPhillip CrauseJohn Darr
ADDRESS307 Henry Street, #111 Alton, IL 62002
Belleville, IL 62025
Granite City, IL 62025
PHONE #618-616-0347
618-910-1634e618-580-3457

All controlled substances and alcohol testing will be conducted in accordance with Parts 40 and 382 of the FMCSR.

I, (Print Name)

have read the above controlled substances and alcohol testing requirements and understand them. I acknowledge receipt of the referral list of Substance Abuse Professionals.

(Employer Representative):
Date:

MANDATORY USE FOR ALL MONTHLY ACCOUNT HOLDERS

IMPORTANT NOTICE REGARDING BACKGROUND REPORTS FROM THE PSP Online Service

1. In connection with your application for employment with BL Logistics LLC. (“Prospective Employer”), it 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 of FMCSA; 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.

The Prospective Employer cannot obtain background reports from FMCSA unless you consent in writing.

If you agree that the Prospective Employer may obtain such background reports, please read the following and sign below:

2. I authorize BL Logistics LLC. (“Prospective Employer”) 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 consenting to 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.

3. 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 I am challenging 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.

4. Please note: 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 FMCSR violations that have been adjudicated by a court of law will also appear, and remain, on a PSP report.


I have read the above Notice Regarding Background Reports provided to me by Prospective Employer and I understand that if I sign this consent form, 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.

Date:
Name (Please Print)

NOTICE: This form is made available to monthly account holders by NICT on behalf of the U.S. Department of Transportation, Federal Motor Carrier Safety Administration (FMCSA). Account holders are required by federal law to obtain a driver’s written or electronic consent prior to accessing the driver’s PSP report. Further, account holders are required by FMCSA to use the language provided in paragraphs 1-4 of this document to obtain a prospective driver’s consent. The language must be used in whole, exactly as provided. The language may be included with other consent forms or language at the discretion of the account holder, provided the four paragraphs remain intact and the language is unchanged.

Attempt:
Authorization to Release DOT Drug and Alcohol / Safety Information – FMCSA22 Gateway Commerce Cntr. Dr. W. Ste 100 Edwardsville, IL 62025  FMCSA Phone: 618-219-4185 Fax: 618-219-4186 
In Compliance with the U.S. Department of Transportation (DOT) regulations (49 CFR 40, 382 and 391) all applicants for safety sensitive positionsmust provide the names and addresses of previous employers for the three year period preceding the date of the application. The applicant mustprovide a signed consent for release of the information listed below in order to be placed in a DOT regulated position.

THIS SECTION TO BE COMPLETED BY APPLICANT (PRINT USING BLACK INK)

I,
SSN:
in accordance with 49 CFR Part 40 authorize andrequest the following companies (list DOT regulated employers during the previous three years) to provide the testing information requestedto the company noted below:
1. Company Name:
Address:
Telephone#
-
Dates of Employment
2. Company Name:
Address
Telephone#
-
Dates of Employment
3. Company Name:
Address:
Telephone#
-
Dates of Employment
If you need additional space check this box and attach a separate sheet.

A copy or fax of this signed authorization form shall be considered equally valid as the original for a period of one year from the date signed.


Date:
Attn:
Company Name:
Fax Number:
Date
Applicant’s Name:
SSN:
Given Dates of Employment:
Start:
End:

THIS SECTION TO BE ANSWERED BY EMPLOYER

The United States Department of Transportation (DOT) regulations (49 CFR Part 40, 382 and 391) require companies that are regulated by the DOT to answer specific questions regarding individuals who were employed by them in a DOT regulated safety-sensitive position within the three previous years. Please answer the following questions concerning DOT mandated alcohol and drug testing, and include relevant details for any questions that are answered yes.

1. Your Company Name & Address:
2. Did this employee hold a DOT sensitive position within your company during the previous 3 years? If yes, check box and continue with additional questions.
3. Did the applicant have an alcohol test with a result of 0.04 or higher alcohol concentration?
4. Did the applicant have verified positive drug tests?
5. Did the applicant refuse to be tested (including verified adulterated or substituted drug test results)?
6. Did the applicant violate any DOT agency drug and alcohol testing regulations or violate the alcohol and controlled substances prohibitions under 49 CFR Part 382 Subpart B, or 49 CFR Part 40?
7. Did a previous employer report a drug and alcohol rule violation to you?

If you answered yes, you must provide the previous employer’s report.

8. If the applicant violated a drug and alcohol regulation, provide documentation of the successful completion of DOT return-to-duty requirements and information on the substance abuse professional (including follow up tests). Please check the appropriate box below:

9. For an applicant who had successfully completed a SAP’s rehabilitation referral, and remained in the employ of the previous referring employer, had the applicant had the following test violations subsequent to the completion of a 49 CFR Part 382.605 or 49 CFR Part 40, Subpart O referral? Please respond to the below by checking the appropriate box below each question below:

a) Did the applicant have any alcohol tests with a result of 0.04 or higher alcohol concentration?
b) Did the applicant have any verified positive drug tests?

c) Did the applicant refuse to be tested (include verified adulterated or substituted drug test results.)

10. Do you know if the applicant failed to undertake or complete a rehabilitation program prescribed by a Substance abuse professional (SAP) pursuant to 49 CFR Part 382.605 or 49 CFR Part 40 Subpart O?

(If this information is unknown by the previous employer (e.g., an employer that terminated an employee who tested positive on a drug test), the prospective motor carrier must obtain documentation of the applicant’s successful completion of the SAP’s referral directly from the applicant.

Did the applicant drive commercial motor vehicles for your company subject to Federal Motor Carrier Safety regulations?
If yes, what type (Check all that apply):
Specify Type:
Was the applicant in a safety-sensitive position subject to DOT drug and alcohol testing requirements?

Please Verify Actual Dates of Employment:

Start:
Actual Position Held:
The applicant named above was employed by us.
Employed as:
from (m/y)
to (m/y)
1. Did he/she drive motor vehicle for you?
If yes, what type?
Doubles/Triples Other (Specify)
2. Reason for leaving your employ:
If there is no safety performance history to report, check here,
sign below and return. ACCIDENTS: Complete the following for any accidents included on your accident register (§390.15(b)) that involved the applicant in the 3 years prior to the application date shown above, or check

here if there is no accident register data for this driver.

DateLocation# Injuries# FatalitiesRecordable? Y/N










Please provide information concerning any other accidents involving the applicant that were reported to government agencies or insurers or retained under internal company policies:
Any other remarks:
Title:
Date:

Completed By (Please Print)

Name:
Date:
Title: