Date City / State Charge Penalty Vehicle Type 23724 W. 83 ... · 23724 W. 83rd Terrace – Shawnee...

23724 W. 83rd Terrace – Shawnee – KS 66227

Application for Employment—§391.21 (DQ-1)

Applicant’s Name: _________________________ Date of Application: _____________________

Current Address: _________________________ Social Security Number: _____________________

___________________________________________ Date of Birth: _____________________

Length of Time at this Address: _________________ Telephone Number: _____________________

Email Address: _____________________________________________________________________________________

Emergency Contact: __________________________ Emergency Contact Number: __________________________

PREVIOUS ADDRESSES FOR LAST THREE YEARS Referred By: _______________________________________

Street City State & Zip Code How Long

LIST CURRENT LICENSE AND/OR PERMITS

State Number Expiration Date

LIST THE NATURE AND EXTENT OF YOUR EXPERIENCE OPERATING DIFFERENT TYPES OF MOTOR VEHICLES (EXAMPLE: BUSES, STRAIGHT TRUCK, TRAILERS, TANKER, ETC)

Type Years of Experience

LIST ALL VEHICLE ACCIDENTS YOU WERE INVOLVED WITH IN THE LAST THREE YEARS

I certify that I have had no accidents in the last three years

Date City / State Nature Of Accident Injuries Fatalities Tows Vehicle Type

LIST ALL OTHER VIOLATIONS FOR WHICH YOU WERE CONVICTED OF FORFEITED BOND / COLLATERAL DURING LAST THREE YEARS

I certify that no convictions or bond forfeitures have occurred

Date City / State Charge Penalty Vehicle Type


PLEASE DETAIL THE FACTS AND CIRCUMSTANCES OF ANY DENIAL, REVOCATION, OR SUSPENSION OF ANY LICENSE, PERMIT, OR PRIVILEGE TO OPERATE A MOTOR VEHICLE

I certify that no such denial, revocation, or suspension has occurred

Please complete all information regarding prior employers during the last three years. If you are applying to operate a Commercial Motor Vehicle (GVWR of 26,001 lbs. or more, ability to transport 16 or more people, or any vehicle requiring placarding for hazardous materials), please include complete information regarding prior employers for the last 10 years for whom you operated like vehicles. Please start with your most recent or current employer (Attach additional sheets if necessary).

Employer Name: Employed From:

City: State: Position:

Phone #: Fax#: Salary:

Contact: Reason for Leaving:

Were you subject to the FMCSR while employed by this employer? Yes No

Was your position “safety-sensitive” requiring Part 40 Drug and Alcohol testing? Yes No













Highest Level of Education: __________________________ Safety Courses: ____________________________

List Any Safety Achievements: _______________________________________________________________________

List Endorsements You Hold: ________________________________________________________________________


MAINTENANCE EXPERIENCE & QUALIFICATIONSPlease detail any mechanical experience you have: (fuel systems, body work, transmission, etc.)

Please list any ASE Certifications:

Have you ever been convicted of a felony? Yes No If you answered yes, please explain the conviction below:

Release of DOT/ FMCSA Drug and Alcohol Testing Information

I hereby authorize release of information from my Department of Transportation regulated drug and alcohol testing records by my previous employer, listed below, to the prospective employer listed below. This information may also be released to the employer’s authorized background check vendor, Concorde, Inc. 1835 Market St., Philadelphia, PA 19103 – 215-563-5555. This release is in accordance with DOT Regulations 49 CFR Parts 40.25, 40.321, 391.23. I understand that the drug and alcohol testing information to be released in Section II-A by my previous employer, is limited to the following DOT-regulated testing items: 1. Alcohol tests with a result of 0.04 or higher; 2. Verified positive drug tests; 3. Refusals to be tested; 4. Other violations of DOT agency drug and alcohol testing regulations; 5. Information obtained from previous employers of a drug and alcohol rule violation; 6. Documentation, if any, of completion of the return-to-duty process following a rule violation.

Release of FMCSA Driving and Safety Information

I hereby authorize release of information from my Department of Transportation driving and safety records by my previous employer, listed below, to the prospective employer listed below. This information may also be released to the employer’s authorized background check vendor, Concorde, Inc. 1835 Market St., Philadelphia, PA 19103 – 215-563-5555. This release is in accordance with DOT Regulation 49 CFR Part 391.23. The information to be released will include my driving safety history and the items identified at 49 CFR 391.23.

Applicant’s Signature X_____________________________

This certifies that this application was completed by me, and that all entries on it and information contained herein are complete and true to the best of my knowledge.

Applicant Signature: X____________________________________ Date: ___________________________


Previous Pre-Employment Alcohol & Drug Testing Statement—§40.25

In accordance with the FMCSA Regulation §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 §40.25(b) (5) and (e).

Applicant’s Name ________________________________________________

The prospective employee is required by §40.25(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? Yes No

2. If you answered yes, can you provide/obtain documentation that you’ve successfully completed the DOT return-to-duty requirements?

Yes No

__________________ _____________________________________________________________

Date Driver Signature


Receipt of Drivers Rights - §391.21 (i) – (j)

Employers who are regulated by the Federal Motor Carrier Safety Administration (FMCSA) must expressly notify an applicant, who has been employed by a Department of Transportation-regulated employer during the preceding three years, that the applicant has certain rights regarding the investigative information that will be provided by his/her previous employer(s). These rights are covered in Part 391.23 (i) – (j) of the Federal Motor Carrier Regulations.

If you disagree and feel that the information previous employers have presented is false or inaccurate, you may request that the information be challenged. We will provide you with the document to detail your request / complaint. The applicant will be responsible for detailing the complaint and returning the document to our recruiting department.

By signing below I acknowledge that Team Drive-Away has provided me with written instructions regarding my rights as defined in Part 391.23 (i) – (j) of the Federal Motor Carrier Safety Regulations. I have reviewed these materials which include information on the following:

Right to Review Information – I have the right to review the information provided by my previous DOT-regulated employer(s). Right to Request Corrections – I have the right to request corrections to information that my previous DOT-regulated employer(s) provides, which I believe contain errors. Right to Rebut Information – I have the right to rebut the information provided by my previous DOT-regulated employer(s).

____________________________________

Driver’s Name

___________________________________ _________________

Driver’s Signature Date

____________________________________ _________________

Motor Carrier Representative Date


PSP Release

In connection with your application for employment with Team Drive-Away, 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 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.

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://dataqs.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:

I authorize Team Drive-Away (“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 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 I 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 2 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.

Date: __________________________ _______________________________________ Signature

___________________________________________ Name (Please Print)


FAIR CREDIT REPORTING ACT DISCLOSURE STATEMENT AND AUTHORIZATION – MVR RELEASE Disclosure It is Team Drive‐Away’s company policy to perform certain background checks of its employees and applicants. This may include checking your previous employment, criminal and civil history, drug/alcohol test records, educational records, driving records, credit, etc. The report may contain information on your character, general reputation, personal characteristics and mode of living. Thus you may be the subject of a “consumer report” or an “investigative consumer report”. The latter is obtained through personal interviews. We will use this information as part of the basis for our decision regarding your employment. This means that your former employers and others may be contacted and a search of public and private records made. We may not obtain this information without your express written consent. You do not have to consent; however, you will not be eligible for employment unless you agree to permit us to obtain this information. To help us obtain this information we sometimes use a consumer reporting agency. That agency is Explore Information Services, LLC (dba. Supervision), 2900 Lone Oak Parkway, Eagan MN 55121, 855‐556‐3553, www.exploredata.com. In the event that we intend to make an adverse decision based on any information obtained, we will tell you and provide you with a copy of what we obtain; we will also provide a copy of your rights in the form prescribed by the Consumer Financial Protection Bureau. If you would like a copy of any report that we receive, you can obtain a copy by making that request to us in writing at this time. Acknowledgement and Authorization I acknowledge receipt of A SUMMARY OF YOUR RIGHTS UNDER THE FAIR CREDIT REPORTING ACT. I authorize Company to make lawful inquiries, including of my prior employers, and other entities and persons to verify my suitability for employment. This may include requests for information regarding my criminal, civil and motor vehicle records. I authorize the release of this information by any prior employer and anyone else having information or documentation about me to Company and Supervision. I authorize Team Drive‐Away or other consumer reporting agencies to provide consumer and investigative consumer reports to you. I agree that so long as I remain employed by the above named employer, that this Disclosure and Authorization shall remain in effect; accordingly it shall not be necessary for me to sign a new Disclosure and Authorization. California, Minnesota and Oklahoma Applicants/Employees: You may receive a copy of the report by making the request to your Team Drive‐Away recruiter. California Applicants/Employees: By signing below, you also acknowledge receipt of a copy of the CALIFORNIA NOTICE REGARDING BACKGROUND INVESTIGATION New York Applicants/Employees: You have a right to receive a copy of any report by contacting Supervision directly. By signing below, you acknowledge receipt of a copy of New York Correction Law Article 23‐A. ____________________________________________________________________________________________ Printed Name of Applicant/Employee Date of Birth Social Security Number ____________________________________________________________________________________________ Signature Date Telephone Number ____________________________________________________________________________________________ List Your Current Addresses ‐ Street/City Zip


Certificate of Compliance with Driver’s License Requirements

§383 & 391

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 16 or more people, or transports hazardous material that require placarding.

The requirements in Part 391 apply to every driver who operates commerce and operates a vehicle weighing 10,001 pounds or more, can transport 16 or more 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. These requirements are in effect as of July 1, 1997. They are as follows:

1. POSSESS ONLY ONE LICENSE: As a commercial vehicle driver, you may not possess more than one motor vehicle operator’s license. If you have more than one license, keep the license from your state of residence and return the additional licenses to the states that issued them. Destroying a license does not close the record in the state that issued it; you must notify that state. If a multiple license has been lost, stolen, or destroyed, close your record by notifying the state of issuance that you no longer want to be licensed by that state.

2. NOTIFICATION OF LICENSE SUSPENSION, REVOCATION OR CANCELLATION: Sections 391.15(b) (2) and 383.33 of the Federal Motor Carrier Safety Regulations require that you notify your employer the next business day of any revocation or suspension of your driver’s license. In addition, Section 383.31 requires that any time you violate a state or local traffic law (other than parking), you must report it within 30 days to: 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.

The following license is the only one I possess:

License number ______________________________

State ______________________________

Expiration Date ______________________________

I certify that I have read and understood the above requirements:

Driver Name: ________________________Signature: _________________________________ Date: ______________


Alcohol and Substance Abuse Policy Information Receipt §382.601

Pre-Employment Testing §382.113 & §382.301 (DAHF-1)

I have been provided a written copy of the Drug and Alcohol Policy and educational materials. My signature certifies receipt of the DOT required information packet, and that I have reviewed the policy, that I have been given the opportunity to ask questions concerning the policy, that I understand the policy, and that I agree to abide by the policy. I further understand that the Company has the right to discipline and/or terminate any contract driver who does not comply with the policy. I agree to comply with the procedures outlined in the policy and I agree that the results of tests may be reported to the Company.

The content of this information covers: Contact information for questions; Which categories of drivers are covered under this policy; Description of safety-sensitive functions; Circumstances for testing, including post-accident testing; Prohibited conduct and its consequences; Testing procedures and requirements, including procedures covered under 49 CRF Part 40; Requirement to submit to testing; Explanation of refusal to submit and consequences; Consequences for violations of the policy, including when a contractor will be removed from duty; The consequences for alcohol concentration levels; Information concerning the effects of alcohol and controlled substances on an individual’s health, work, and personal life; Signs and symptoms of abuse; and Available methods of intervention when an alcohol or controlled substance problem is suspected.

_____________________________________________________________________________________

I understand that before I can perform safety-sensitive duties for this DOT-regulated employer, Team Drive-Away, I must first undergo testing for controlled substances. All testing will be conducted in compliance with DOT requirements. This testing will be coordinated with the recruiting department.

After a contract is awarded to a driver they are subject to random screening, post-accident screening, and reasonable suspicion screening. The situations and process for each of these is outlined in The Company’s Alcohol and Substance Abuse Policy.

I understand I will be tested for:

Marijuana, Cocaine, Phencyclidine (PCP), Opiates, and Amphetamines [DOT 5 Panel Drug Screen] prior to beginning work in a safety sensitive position. I also understand that this same 5 Panel test, in conjunction with Alcohol testing will be utilized for post-accident, random, and reasonable suspicion testing.

Print Name: ________________________ Signature: X__________________________ Date: _________


Safety Performance History Investigation—§391.23(f) (DIH-1) I hereby authorize you to release the information requested to Team Drive-Away for the purpose of an employment background investigation that is required by the US DOT Federal Motor Carrier Safety Regulations, §382.413, §40.25 and §391.23. I understand that information released pursuant to this document is limited to DOT-regulated testing items, including pre- employment testing results, occurring during the previous three (3) years. I understand and agree that this information will only be used for the purposes stated, and I release all parties from any and all liability which may result from furnishing such information.

Printed Name: ____________________ Signature: X____________________ SSN: ________________ Date: ___________ Top Section Applicant – Bottom Section Previous Employer

___________________________________________________________________________________________

The individual listed above has applied for a position of commercial driver with Team Drive-Away. This applicant has named ____________________ as a previous employer from ______________________ to ______________________, and we are investigating the employment history as required by the FMCSR.

Employed from _______________ to ________________ Position held________________________________

This employee was not in a safety sensitive position and not subject to FMCSA Part 40 regulations.

What type of equipment did he/she operate? Straight truck ____ Tractor-trailer _____Other__________________

In the past three years, was he/she involved in any vehicular accidents while employed by you? Yes ____ No ____

No accident information to report (defined by Part 390.5)

Date_____________ Type __________________________ Fatalities ____ Injuries ____ Tow ____



No prohibited drug and/or alcohol conduct to report.

In the past three (3) years did he/she

Test 0.04 or greater for alcohol concentration? Yes or No

Test positive for controlled substance? Yes or No

Refuse to be tested while employed? Yes or No

Have any other violations of DOT agency drug /alcohol testing regulations? Yes or No

Following a positive result, failed to complete a rehabilitation program? Yes No N/A Unk

Have any testing violations following completion of a rehabilitation referral? Yes No N/A Unk

Was information obtained from previous employers of a drug or alcohol rule violation? Yes or No

If yes to any of the drug and alcohol related questions, please provide the documentation to verify the individual’s successful completion of the return to duty process.

Part 391.23 requires a previous employer regulated by the DOT to provide a specific contact name when responding to a Safety Performance History Inquiry. The driver may choose to contact you regarding the information you provide.

Contact Name: ________________ Telephone Number: __________________ Date: _____________ Fax: ________________

Signature of Company Official Releasing Information: __________________________________

Please return to 913-601-3095 / Attn: Recruiting


Record of Duty Status - New or Intermittent Driver - §395.8 (j)(2) (DIH-5)

A Record of Duty Status must be obtained from drivers being used for the first time, or those that are used intermittently, and must detail the hours worked for the seven (7) days preceding the start or resumption of work. The Company shall have the driver complete this document, and shall use the information supplied by the driver to ensure that the driver will not exceed the FMCSR Hours of Service requirements upon the start of work.

Driver Name: ____________________________ Date of First Log: _________________

Day (Preceding) 1 2 3 4 5 6 7 Total Date

Hours Worked

I was last relieved from work on ____________________ at _______________ AM / PM.

(Date) (Time)

I certify that the information provided by me above is true and correct to the best of my knowledge.

Driver Signature: _____________________________________ Date: ______________________

Supervisor::_________________________________________ Date: ______________________

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 begin working with Team Drive-Away and I begin working for any additional employer(s) for compensation, I must inform Team Drive-Away immediately of such employment activity.

____________________________________ _________________

Driver’s Signature Date


Annual Certificate of Violations and Supervisor Review—§391.27 (DQ-5)

In accordance with the FMCSA Regulation §391.27:

I certify that the following is a true and complete list of traffic violations (other than parking violations) for which I have been convicted or forfeited bond or collateral during the past 12 months.

Driver’s Name ________________________________________________ Date ____________________

Date Offense Location Vehicle Type

Check the box if you had no violations in previous 12 months

______________________ _________________________________________________________________ Date Driver Signature

Team Drive-Away 23724 W. 83rd Terrace, Shawnee, KS 66227 Motor Carrier Name Motor Carrier Address

________________________________________________________________________________________

OFFICE USE ONLY

Reviewed By: ____________________________________

In accordance with the Department of Transportation Section §391.25:

I have reviewed the above driver’s motor vehicle record, and have found that the above driver:

Meets minimum requirements for safe driving? Yes No

________________________________ _______________________________________

Signature Date


FMCSR SAFETY TRAINING ACKNOWLEDGEMENT—§390.3

The Federal Motor Carrier Safety Regulations (FMCSR), require that every driver and employee have instruction regarding, all applicable regulations in 49 CFR Part 390 as well as the General and related subchapters of Parts 391-399.

__________________________________________________________________________________________________

I have been trained and instructed on the Federal Motor Carrier Safety Regulations and shall comply with all applicable regulations. The training included explanations of:

- General Applicability and Definitions of the FMCSR (Part 390)

- General Requirements and Information required by the FMCSR (Part 390)

- Qualification of Drivers (Part 391)

- Driving of Commercial Motor Vehicles (Part 392)

- Parts and Accessories Necessary for the Safe Operation (Part 393)

- Hours of Service of Drivers (Part 395)

- Inspection, Repair, and Maintenance (Part 396)

- Transportation of Hazardous Materials (Part 397)

- Employee Safety and Health Standards for employers and drivers operating trucks and truck-tractors having high-profile cab-over-engine configurations.

- Hands Free Cellular Phone Usage and No Texting (FMCSA 35-11)

http://www.fmcsa.dot.gov/driver-safety/distracted-driving/mobile-phone-restrictions-fact-sheet

Cargo Securement § 392.9, 393.100 – 136:

http://www.fmcsa.dot.gov/rules-regulations/administration/fmcsr/fmcsrruletext.aspx?reg=392.9


- Inspecting Cargo

- General Securement Standards

- Performance Criteria of Securement Systems

- Securing Particular Articles of Cargo

- Determining Working Load Limits (WLL)

- Determining Aggregate Working Load Limits (AWLL)

- Determining the minimum number of tie downs needed to secure cargo for different lengths and weight

- Front-end structure requirements


The training also included commodity-specific lessons and instruction. I was trained in the securement of the following as it applies to my work functions:

- Driveaway Service

- Securing Tow Vehicles

- Boom Related Drive Away Service

Certificate of Training on the CDL Regulations—§383.51


- Being under the influence of alcohol as prescribed by State law

- Being under the influence of a controlled substance

- Having an alcohol concentration of 0.04 or greater while operating a CMV*

- Refusing to take an alcohol test as required by State law

- Leaving the scene of an accident

- Using a vehicle to commit a felony

- Driving with a suspended, cancelled, or revoked CDL, or while being disqualified*

- Causing a fatality with a CMV*

- Using a vehicle to manufacture, distribute, or dispense a controlled substance

- Speeding excessively

- Driving recklessly

- Making improper or erratic lane changes

- Following too closely

- Violating a traffic law (not including a parking ticket) arising in connection with a fatal accident

- Driving a CMV without a CDL*

- Driving without a CDL on the driver’s person*

- Driving a CMV without the proper class of CDL*

Driver Name: ________________________ Signature: _____________________________Date: ____________


Contract Driving Questionnaire (PF-2)

CONTRACT DRIVING POSITION

This position is an independent contract position. You will be responsible for your own over the road expenses, including but not limited to fuel, food, and lodging. Do you agree to this contract condition?

Yes / No

As an independent contract driver you will be subject to pre-hire, random, post-accident, and reasonable suspicion testing. Do you agree to this contract condition?

Yes / No

Team Drive-Away pays independent contractors when contracts and support paperwork are complete. Your pay will be sent the next business day after your paperwork is received (Logs, BOLs, Receipts, etc). You must send in your paperwork upon delivery. Do you agree to this contract condition?

Yes / No

As an independent contractor you will receive a 1099 form at the end of the year. Team Drive-Away will not be deducting Federal taxes, State taxes, or Social Security from your paycheck. You will be responsible for calculating and paying tax amounts. Do you agree to this contract condition?

Yes / No

As a contract driver you will be paid based off the billed mileage. We bill mileage based off of computer routed mileage. Pay will not be based off of actual odometer readings. Do you agree to this contact condition?

Yes / No

You can be advanced up to 65% of the haul pay, upon verification that you have picked up your load. Do you agree to this contract condition?

Yes / No

This contract position requires you keep a DOT logbook. Do you know how to maintain a log book?

Yes / No

You will have an escrow deposit withheld from your pay at a rate of 10% per gross load amount until your contract escrow amount is reached. Do you agree to this contract condition?

Yes / No

I am at least 23 years old?

Yes / No

If I work in decking operations, I understand I must be able to lift and carry up to 100 lbs. repeatedly throughout the day?

Yes / No

Print Name: _________________________ Signature: X_________________________ Date: _________


Contract Hauler Agreement

CONTRACT DRIVING POSITION

This agreement has been entered into this __________ day of __________________, 20 and between _______________________(Hauler) and Team Drive-Away Inc. (Broker).

The parties mutually agree as follows:

1. INDEPENDENT CONTRACT HAULER STATUS

The relationship of the Hauler to the Broker under this agreement is that of an independent contractor, and not that of an employee of the Broker. Except as otherwise provided in this agreement, the Hauler is to determine the manner, details and means of performing the services and conforming to regulatory requirements and specifications of the customer. The Hauler will hold the Broker harmless for failure to make federal, state or local income tax payments in connection with any income earned by the Hauler under this agreement, or for failure to make any required contributions for Social Security, Medicare, or related payment obligations on behalf of the Hauler.

2. RESPONSIBILITY OF HAULER

A. The Hauler may accept any reasonable dispatch provided to him by the Broker.

B. The Hauler will transport and move in an efficient and prompt manner complying with all applicable requirements of federal, state, and local governments.

C. The Hauler will supply all decking and/or towing equipment, tools and supplies necessary to transport motor vehicles contracted by the Broker.

D. The Hauler will pay all expenses incurred in hauling assigned vehicles, except general liability insurance, fees, and certain permits furnished by the Broker. This includes any and all expenses the Broker incurs if the Hauler cannot complete the assigned load.

E. The Hauler will indemnify the Broker and hold the Broker harmless for the loss of or damage to the equipment used for performing services under this Agreement.

F. The Hauler will determine the most efficient and economical route for moving units from origination to destination and is responsible for calling the customer directly for directions or other information not involving the Broker’s daily business.

G. The Hauler will perform the Hauler’s duties under this agreement in a competent, efficient, and business-like manner. The Hauler will not utilize the trucks to haul any other goods nor use the vehicle to provide any other services except those required to transport the load to the customer.

H. The Hauler will contact the Broker by phone, email, text, or in person at least once per day. This is necessary to maintain contact to verify the Hauler’s status and welfare.

I. The Hauler will not carry any unauthorized passengers while performing services under this agreement or use our driveaway plates for any reason other than official driveaway operations of Broker.

J. As a pre-condition to payment by the Broker under this agreement, the Hauler will deliver or mail to the Broker on the day following delivery of the load the following:

1. Signed (at origin and destination) Bills of Lading and Inspection Reports. Initial ______


2. Driver’s Log Sheets, up to and including the final delivered load and any off-duty status logs in between loads as well as copies of all previous logs used to run loads for other companies. Logs should be properly completed showing all fuel stops and walk-around inspections and miles-by-state driven daily. Logs must be turned in within 10 calendar days to be considered current with the Broker.

3. Original copies of all fuel receipts.

4. All reimbursable expense receipts (oil, tire repairs, breakdowns, second wreckers, DEF, etc.) and two non-reimbursable receipts for log verification.

5. Motel receipts when a layover is previously determined and authorized.

K. The Hauler is responsible for posting the Broker’s plates, placards and IFTA information when transporting a vehicle for the Broker. The Hauler will cover the customer’s USDOT number and company name by using the placards provided by the Broker. At the conclusion of the delivery, it is the responsibility of the Hauler to retain the Brokers plates and placards.

L. The Hauler will return promptly to the Broker, upon termination of this agreement, all license plates, permits, identification devices, and evidence of motor carrier permits which Broker obtained and placed in the Hauler’s possession. The Hauler authorizes the Broker to withhold the Hauler’s escrow (outlined in Section 3), from payments due the Hauler under this agreement for the use of these permits and plates. Upon termination of this agreement, any outstanding amounts will be applied to the Hauler’s account and included in calculation of any final settlement.

M. The Hauler will complete a minimum of two (2) loads each month in order to remain active with the company. The Hauler’s contract is subject to termination if the Hauler is inactive for more than 2 months. The Hauler also agrees to call dispatch by 9AM daily when assigned a load by Team Drive-Away. If the Hauler does not call, dispatch will be checking in with the Hauler for a status update.

N. The Hauler is responsible for keeping a copy of this executed Contract Hauler Agreement in any vehicle driven for the Broker.

O. The Hauler is granted exclusive possession, control and use of the truck(s) during the terms of this agreement for any load that the Broker has dispatched to the Hauler. The Hauler assumes responsibility for and agrees to operate the vehicle(s) in a safe and legal manner while transporting the vehicle(s) for the Broker.

P. Any Haulers, operating as deck drivers, are responsible for the first $200.00 of decking fees, unless agreed to by the Broker otherwise.

3. PAYMENT FOR SERVICES OF HAULER

1 Unit $ 0.67 per mile 2 Units $ 1.10 per mile

3 Units $ 1.25 per mile 4 Units $ 1.40 per mile

Booms $ 1.12 per mile Tractor Trailer $ 0.85 per mile

** (Haulers will be paid $ .05 / mile more on their deck miles once they achieve 100,000 damage-free miles) **

** (Haulers will be paid $ .10 / mile more on their deck miles once they achieve 200,000 damage-free miles) **

AIR SHIELDS: $ 75.00 EACH

EXTRA STOPS: $ 25.00 EACH

Initial ______


A. Haulers joining the Broker as a Trainee in the deck training program must operate in a “hand-held” status with a Trainer until the Trainer clears the Trainee for solo operation. Deck load pay is diminished by .10 per mile until the Hauler exits “handheld” status.

B. All decked loads will be based on an 800 mile minimum unless the Broker and the Hauler agree upon Hauler’s pay prior to the load being hauled.

C. Loading or securing equipment, such as decking or connecting the tow vehicle is the responsibility of the Hauler and the pay for this time is included in the per mile pay.

D. A fuel surcharge will be paid according to the Broker’s policy in force during the contract. E. The payment for services rendered will be within two business days provided that the Hauler

submits all documents required to bill the customer, which include the following: Executed BOL, Logs, Fuel Receipts, Authorized Layover Receipts, and Authorized Repair Receipts. Failure to submit completed and required documents will delay payment.

F. All of the Hauler’s payments from the Broker under this agreement are accessible at drivers.teamdriveaway.com. To access the website, the Hauler must use login credentials provided by the Broker.

G. USDOT Inspections with ZERO violations, warnings, or citations: $ 100.00 paid to Hauler.

4. DEDUCTIONS FROM PAYMENTS TO HAULER

The Hauler hereby authorizes the Broker to deduct from the payments to the Hauler the following items:

A. Cash advances made to the Hauler. B. Car rentals for which the Hauler is responsible. C. The loss of driveaway plates provided by the Broker. D. Any finance charge assessed to an individual carrying a negative balance. This is calculated at 1.5%

per pay period based on the entire negative balance. E. Settlement deductions covering the cost of insurance elections. If the Hauler fails to haul enough

loads to cover the insurance premium for the month, the Broker will debit the Hauler’s escrow account to cover the premium.

F. Garnishments or court orders. G. Damages as outlined in Section 5 – Escrow, Damages, Claims, and Insurance H. The Broker charges drivers a fee for repeated violations. $25.00 for Non Out of Service and $50.00

per Out of Service violation. I. At the request of the Hauler, the Broker will provide an accounting to the Hauler of their escrow

account.

5. ESCROW, DAMAGES, CLAIMS, and INSURANCE

A. The Hauler agrees to allow the Broker to hold an escrow set at $1,500 (Single Haulers and Boom Haulers) or $2,500 (Deck Haulers) unless another amount is previously established with the Broker.

B. The Hauler agrees to pay for damages incurred by the Broker for motor vehicles transported by the Hauler, regardless of fault, up to $2,500 or their deductible buy back limit detailed in section 5.C. Unless otherwise agreed to by the Broker and Hauler, the Broker will apply escrow balance to damages or insurance deductible.

C. Every Hauler has the option of enrolling in a supplemental insurance program which buys down the $2,500 deductible for every claim to $500, making the maximum out of pocket cost to a Hauler $500 for each claim. Deductible Buy Back Program is an insurance policy that covers the Hauler’s responsibility in damages in the case of a liability or cargo claim with the Broker.

Initial ______


1. In the event a Hauler has a liability or cargo claim, the Broker will deduct $500 from the Hauler’s escrow and the Deductible Buyback Program will cover the remainder of the Hauler’s charges. If the Hauler elects to enroll in the deductible Buy Back Program, the Broker will spread the cost of the premium ($82.00 per month) over multiple settlement deductions each month.

2. If the Hauler does not elect to participate in the Deductible Buy Back program, the Hauler is responsible for the full $2,500 of any liability or cargo claim – unless otherwise agree to by the Broker.

D. The Broker will provide a written explanation to the Hauler for any deduction of property damage before the deduction is made.

E. All Haulers must carry an Occupational Accident Policy to operate for the Broker. Haulers who do not carry a personal policy will be automatically enrolled in an Occ/Acc Policy with One Beacon through Team Drive-Away and charged the premium for the coverage through settlement deduction. If a Hauler carries a personal policy, they must list Team Drive-Away as an “interested party” on the policy and provide a copy to the Broker. For Haulers automatically enrolled in coverage, the Broker will supply a copy of this policy at the request of the Hauler.

1. The premium for Occ/Acc coverage through One Beacon is $12.00 per day not to exceed $204.00 per month. Deck Haulers will have the entire premium deducted out of their first settlement for each month unless the Broker agrees to some other arrangement.

6. CONDITIONAL STATUS

A. Any Hauler who fails to maintain a satisfactory safety performance level agrees to being placed in a conditional status. Satisfactory performance is based on violation, claims, and citation history.

B. Any Hauler in a conditional status may be required to participate in additional safety training and any other programs assigned by the Broker.

C. The Broker’s goal will be to assist the Hauler in successful safety performance, thus being removed from the conditional status.

D. The contract of any Hauler who continues to perform poorly while in a conditional status is subject to termination.

7. RESPONSIBLITIES OF BROKER

A. The Broker will pay the Hauler for the delivery of motor vehicles in accordance with and subject to all the terms of this agreement.

B. The Broker will provide adequate Liability Insurance and Garage Keepers Insurance subject to all requirements as set forth by the Interstate Commerce Commission. The Broker has the legal obligation to maintain insurance coverage for the protection of the public. The Broker will maintain Liability and Cargo Insurance for driveaway operations.

C. The Broker will furnish to the Hauler:

1. I.C.C. authorities

2. Kansas driveaway plates ***Authorized Use Only***

3. UCR authority and certain other permits

4. Com-Data cards and checks

Initial ______


D. The Broker will make cash advances to the Hauler, in such amounts, not to exceed 65% of load pay (except in cases of emergency), and from time to time as the Broker may deem necessary. No more than $500 (Deck Haulers) $300 (Single Haulers) / day until a full escrow deposit is collected.

E. The Broker will reimburse the Hauler for expenses incurred on the customer’s behalf for repair and maintenance to the customer’s equipment or major repairs authorized by the Broker and / or customer.

F. The Broker assumes liability for fines for overweight and oversized loads where the customer indicates the unit being transported is not oversize or overweight. However, the Hauler is responsible for any overweight or oversize fines resulting from acts or omissions. The Hauler is required to measure the overall dimensions of each load. Any load that is hauled over the maximum legal dimensions is at the sole discretion and responsibility of the Hauler.

G. The Broker will be responsible for applying the money specifically deducted from the Hauler’s settlement for insurance coverage to the insurance carrier or the carrier’s representative.

8. TERMINATION

A. This agreement may be terminated by either party upon seven days’ notice. The Broker may terminate this agreement with no prior notice to the Hauler based upon any dishonest act of the Hauler or upon the Hauler’s failure to perform the obligations outlined in Section 1. The Hauler may not terminate this agreement during the course of a haul for a customer. All notices shall be deemed given when personal communication of such event is delivered via telephone, text, email, in person or when sent by fax to the other party or when deposited in the U.S. Mail, postage prepaid, at the following address:

Broker’s Mailing Address: 23724 W. 83rd Terrace, Shawnee, KS 66227

9. PAYMENT UPON TERMINATION

Upon termination of this agreement, the Broker will make a final settlement with the Hauler and return escrow funds within thirty (30) days, providing there are no outstanding or unresolved expenses or claims against the Hauler and all properties of the Broker, including but not limited to driveaway plates, authority books, fuel permits, insurance certificates, I.C.C. authorities and any remaining Com-Data cards or checks, have been returned to the Broker. If the Hauler fails to return these items within ten (10) days, the Hauler thereby surrenders to the Broker any deposit(s) previously withheld.

10. COLLECTIONS

Upon termination of this agreement, the Hauler acknowledges the right of the Broker to collect on unsettled amounts not covered by the Hauler’s escrow account. The Hauler agrees to pay outstanding or unresolved expenses that arise from fines, fees, damage, recovery, unreturned property of the Broker, or the cost of covering an abandoned load. The Hauler acknowledges that the Broker reserves the right to take action against the Hauler for unresolved amounts through a collection agency. All expenses incurred for such efforts will be the responsibility of the Hauler.

11. MISCELLANEOUS

This document is the entire agreement between the parties. It shall not be amended except in writing signed by both parties. Time is of the essence in the performance of these obligations imposed under this agreement. The duties and obligations may not be assigned or delegated by the Hauler or Broker to another without the expressed consent of the other party to this agreement. Failure of the Broker to seek strict enforcement of this agreement in any particular instance shall not constitute a waiver of the Broker’s right to strict enforcement of this agreement on any other occasion. This agreement may be renewed annually by an addendum.

Initial ______


12. GOVERNING LAW

The agreement shall be governed by and construed and enforced in accordance with the laws of the state of Kansas.

Broker Representative: ________________________ Hauler Signature: ________________________

Team Drive-Away, Inc. 23724 W. 83rd Terrace – Shawnee – KS


Employment Eligibility Verification (PF-6)

A. CONTRACT EMPLOYEE INFORMATION AND VERIFICATION: (To be completed and signed by the contracted employee)

Name: (Print or Type) Last First Middle Birth Name

Address: Street Name and Number City State Zip Code

Date of Birth (Month/Day/Year) Social Security Number

I certify that I am:

A citizen or national of the United States.

An alien lawfully admitted for permanent residence (Alien Number A __________________________).

An alien authorized by the Immigration and Naturalization Service to work in the United States (Alien Number A ____________).

Or Admission Number _____________________. Expiration of employment authorization, if any _______________________.

I attest, under penalty of perjury, that the above information and documents that I have presented as evidence of identity and employment eligibility are genuine and relate to me. I understand that federal law provides for imprisonment and/or fine for any false documents in connection with this certification.

X

Signature Date (Month/Day/Year)

CERTIFICATION: I attest, under penalty of perjury, that I have examined the documents presented by the above individual, that they appear to be genuine and to relate to the individual named, and that the individual, to the best of my knowledge, is eligible to work in the United States.

________

Name Signature Date

Team Drive-Away 23724 W. 83rd Terrace, Shawnee KS 66227

Employer Name Address

OFFICE INSTRUCTIONS: Examine one document from List A and check the appropriate lines; or examine one document from List B and one from List C and check the appropriate lines. Provide the Document Identification Number and Expiration Date for the document checked.

List A List B List C

Documents that Establish Documents that Establish and Documents that Establish

Identity and Employment Eligibility Identity Employment Eligibility

__1. United States Passport __ 1. A State-issued driver’s license or a __1. Original Social Security Number

__2. Certificate of United States Citizenship State issued I.D. card with a photograph Card (other than a card stating it

__3. Certificate of Naturalization or information, including name, sex, date is not valid for employment)

__4. Unexpired Foreign Passport of birth, height, weight, and color of eyes __2. A birth certification issued by

Attached Employment Authorization (Specify State___________________) State, county, or municipal authority

__5. Alien Registration Card with ___2. U. S. Military Card bearing a seal or other certification

Photograph ___3. Other (Specify document and issuing authority) __3. Unexpired INS Employment

_____________________________________ Authorization Specify Form #

Document Identification Document Identification Document Identification

#_________________________ #___________________________ #_________________________

Expiration Date (if any) Expiration Date (if any) Expiration Date (if any)

#_________________________ # ___________________________ #________________________


Occupational Hazard Insurance (PF-4)

Team Drive-Away, Inc. requires all drivers to be covered by an occupational hazard insurance policy. As an independent contractor in the event of an accident or injury, it is your sole responsibility to cover any medical expenses you may incur. We do not allow any driver to perform work for our customers without a policy.

Please check ONE of the following options:

I have my own personal occupational hazard insurance policy and will provide a copy of it to Team Drive-Away. I understand by signing below I am refusing to be covered by Team Drive-Away’s Policy. Do not fill out the One Beacon Insurance form.

I need occupational hazard insurance coverage and will fill out the One Beacon Insurance form. I understand by signing below I will fill out the One Beacon Insurance form and be enrolled in Team Drive Away’s Insurance policy.

Signature: X ___________________________________ Date: _______________________

It is important to keep your self-elected insurance current. If your insurance policy does not stay current or expires for any reason, Team Drive-Away will cover your Occupational Hazard Insurance until your self-elected policy is re-instated. The deductions for the premiums will be automatic.


Atlantic Specialty Insurance Company

Canton, MassachusettsDRIVER ENROLLMENT AND BENEFICIARY FORM

TRUCKERS OCCUPATIONAL ACCIDENT INSURANCETeam Drive-Away, Inc. 216-000-134

Please Print:

Name: ______________________________________________________ Male: ______ Female: ______

Street Address: _______________________________________ City: ________________ State: ______ Zip: ________

Social Security Number: ____________________ Date of Birth: ________________ Email: ___________________________

Home Telephone Number: __________________________________ Cell Telephone Number: ________________________________

Name of Beneficiary: ______________________________________ Relationship of Beneficiary: ______________________________

CDL or Required License Number: ______________________________ Number of Years of Experience: ____________

Contracted by (Name of Company): Team Drive-Away, Inc. Effective Date of Contract ________________

Street Address: 23724 W. 83rd Terrace City: Shawnee State: KS Zip: 66227

Motor Carrier Telephone Number: 913-825-4776 Fax Number: 913-825-4777 Motor Carrier E-Mail Address: [email protected]

FRAUD STATEMENTIt is a crime to provide false or misleading information to an insurer for the purposes of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny benefits if false information materially related to a claim was provided by the applicant.

In providing this information, I, the undersigned, understand and hereby state that:

1. To the best of my knowledge and belief, all information on this Form is complete and truthful;2. This is not a contract for Statutory Workers’ Compensation Insurance, and neither I nor my carrier become participants in the Workers’

Compensation system by purchasing this insurance; and3. If, based on the information supplied in this Form, I am not eligible for coverage, premium will be refunded and no claims will be payable.

By my signature below, I, the undersigned, also authorize any licensed physician, medical practitioner, hospital, clinic or other medical or medically related facility, insurance company or any other organization, institution or person that has any records, including any medical records, to furnish such information or copies of records to Atlantic Specialty Insurance Company, the motor carrier or the motor carrier’s designee. A photographic copy of this authorization shall be as valid as the original.

IF THE INFORMATION PROVIDED IN THIS FORM IS FRADULENT,THE INSURER HAS THE RIGHT TO RETURN PREMIUM AND CANCEL COVERAGE.

In order to verify the information provided in this Form, I, the undersigned, give the Insurer authority to examine the records that are maintained by the motor carrier.

I certify that I am an independent contractor, paid by 1099 tax form, not as a W2-employee.

Driver’s Signature: _______________________________ Date: ____________________

Motor Carrier Representative’s Signature: __________________________________________

Payment Authorization: I authorize the above named motor carrier, with whom I have a contract, to take monthly deductions, equal to my premiums, from my settlement account on my behalf, and to remit these funds to Atlantic Specialty Insurance Company.

I UNDERSTAND THAT THE COST OF THE INSURANCE IS MY SOLE OBLIGATON AND RESPONSIBILITY, regardless of the above arrangement of premium payment. I agree that I will forward any amount due and owing to Atlantic Specialty Insurance Company, upon demand, for any insurance at any time my account remains unpaid.

Signature: _________________________________________________ Date: ________________


Documents to Turn In to Recruiting

PLEASE COMPLETE AND RETURN ALL PAGES

Please be prepared to send us copies of the following documents:

- Driver’s License - Social Security Card - Long Form Physical - Medical Card - Medical Self Certification / CDL Medical Card Merger (Receipt or proof)

If you will be using a tow vehicle for decking or singles driving:

- Copy of Tow Vehicle Insurance Policy

We cannot assign loads to you until these documents are received. Also, please make sure they are legible / readable copies. If we cannot read them we must request new copies.

Please sign and complete all the attached documents. The Safety Performance History Investigation document only needs your printed name, signature, and date of authorization (all three copies). Please make note of any document that has “OFFICE USE ONLY” or “OFFICE INSTRUCTIONS” and do not fill out those areas of the paper work. These are usually reserved for the bottom half of the page.

We use Big Road for our logs, receipts, BOL’s, and any other documents that need to be sent. If you have a smart phone, please go to your app store and download the Big Road application. We encourage you to get to know the application and use the tutorial videos to learn how to use Big Road. Using this application will save you time and money:

- No waiting or paying for a fax to send in logs, receipts, or BOL’s - Automatically completes your logs for you - Provided for free – Team Drive-Away pays for the service - Instant messenger capability to your dispatcher through the application - Keeps track of your mileage

Attached to the email you received is the company’s drug and alcohol policy. Please make sure you understand the policy and feel free to ask any questions about the company’s stance on drugs and alcohol. In addition, there are links to required training material found on the FMCSA’s website. Please review this material on Cargo Education, CDL Regulations, and FMCSR Safety Regulations.

We may send out t-shirts and jackets periodically, please let us know what your shirt size is so we don’t send you the wrong size:

Shirt Size: _______________

If you have any questions about documents or want to check on the status of your application, please feel free to contact the recruiting department at 913-825-4776.

Date City / State Charge Penalty Vehicle Type 23724 W. 83 ... · 23724 W. 83rd Terrace – Shawnee...

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