Driver Application – Davis Iron Works

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GENERAL INFORMATION

Name(Required)

First Middle Last

Email(Required)

Social Security No.(Required)

Position Applying For(Required)

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, non-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 interview(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.

Name (signature of agreement)(Required)

Date(Required)

List your addresses of residency for the past 3 years.

Current Address

Street Address City State ZIP Code

How long have you lived here?

Previous Address

Street Address City State ZIP Code

How long have you lived here?

Previous Address

Street Address City State ZIP Code

How long have you lived here?

Previous Address

Street Address City State ZIP Code

How long have you lived here?

Cell No.(Required)

Home Phone No.

Are you legally eligible for employment in the USA?(Required)

Yes

Date of birth

Required for Commercial Drivers

Can you provide proof of age?

Yes

Have you worked for this company before?

Yes

Where?

Dates: From

Dates: To

Rate of Pay

Position

Reason for leaving?

Are you employed now?(Required)

Yes

How long since leaving last employment?

Who referred you to this company?

Rate of pay expected?(Required)

Have you ever been bonded?

Yes

Answer only if a job requirement

Name of bonding company

Have you ever been convicted of a felony?

Yes

Please explain fully. Conviction of a crime is not an automatic bar to employment-all circumstances will be considered.

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)?

Yes

Explain what you are unable to perform 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.)

Employer

Employer Address

Street Address City State ZIP Code

Position

Supervisor

Employer Phone

Employer Email Address

Employer Fax Number

Salary / Wage

Start Date

End Date

Were you subject to the FMCSRs while employed?

Yes

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

Reason for Leaving

Employer

Employer Address

Street Address City State ZIP Code

Position

Supervisor

Employer Phone

Employer Email Address

Employer Fax Number

Salary / Wage

Start Date

End Date

Were you subject to the FMCSRs while employed?

Yes

Was your job designed as a safety-sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirements of 49 CFR part 40?

Yes

Reason for leaving

Employer

Employer Address

Street Address City State ZIP Code

Position

Supervisor

Employer Phone

Employer Email Address

Employer Fax Number

Salary / Wage

Start Date

End Date

Were you subject to the FMCSRs while employed?

Yes

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

Reason for leaving

Employer

Employer Address

Street Address City State ZIP Code

Position

Supervisor

Employer Phone

Employer Email Address

Employer Fax Number

Salary / Wage

Start Date

End Date

Were you subject to the FMCSRs while employed?

Yes

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

Reason for leaving

Employer

Employer Address

Street Address City State ZIP Code

Position

Supervisor

Employer Phone

Employer Email Address

Employer Fax Number

Salary / Wage

Start Date

End Date

Were you subject to the FMCSRs while employed?

Yes

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 40?

Yes

Reason for leaving

Employer

Employer Address

Street Address City State ZIP Code

Position

Supervisor

Employer Phone

Employer Email Address

Employer Fax Number

Salary / Wage

Start Date

End Date

Were you subject to the FMCSRs while employed?

Yes

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 40?

Yes

Reason for leaving

* 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.

The Federal Motor Carrier Safety Regulations (FMCSRs) apply to anyone operating a motor vehicle on a highway in interstate commerce to transport passengers or propery 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.

INQUIRY INTO SAFETY PERFORMANCE HISTORY DATA

AUTHORIZATION/SPECIFIC WRITTEN CONSENT

I hereby authorize my previous employer listed above to release and forward information requested within this document concerning my Alcohol & Drug Testing records under 49 CFR Part 40 within 3 years from the date of this application.

Information is authorized to be released to Metals 2 Go at P.O. Box 20425, Waco, Texas 76702

In compliance with Section 40.25(g) and 391.23(h), release of this information must be made in a written form that ensures confidentiality (i.e. fax, email, or letter).

Signature (authorizing release of information)(Required)

Date (date signed)(Required)

INQUIRY INTO SAFETY PERFORMANCE HISTORY DATA

AUTHORIZATION/SPECIFIC WRITTEN CONSENT

Information is authorized to be released to Metals 2 Go at P.O. Box 20425, Waco, Texas 76702

In compliance with Section 40.25(g) and 391.23(h), release of this information must be made in a written form that ensures confidentiality (i.e. fax, email, or letter).

Signature (authorizing release of information)(Required)

Date (date signed)(Required)

ACCIDENT RECORD

For past 3 years or more. If none leave blank.

Date of Last Accident

Nature of accident

Fatalities

Injuries

Hazardous Material Spill

Next Previous Accident Date

Nature of accident

Fatalities

Injuries

Hazardous Material Spill

Next Previous Accident Date

Nature of accident

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

Location

Date

Charge

Penalty

Location

Date

Charge

Penalty

EXPERIENCE & QUALIFICATIONS - DRIVER

List all driver licenses or permits held in the past 3 years.

DL State

License No.

Type

Expiration Date

DL State

License No.

Type

Expiration Date

DL State

License No.

Type

Expiration Date

Have you ever been denied a licenses, permit or privilege to operate a motor vehicle?

Yes

Has any license, permit or privilege ever been suspended or revoked?

Yes

If the answer to either of the above questions is Yes, give details.

DRIVING EXPERIENCE

Straight Truck

Yes

Type of Equipment

Van

Tank

Flat

Dump

Refer

Approx. No. of miles (total)

Start Date

End Date

Tractor and Semi-Trailer

Yes

Type of Equipment

Van

Tank

Flat

Dump

Refer

Approx. No. of Miles (total)

Start Date

End Date

Tractor - Two Trailers

Yes

Type of Equipment

Van

Tank

Flat

Dump

Refer

Approx. No. of Miles (total)

Start Date

End Date

Tractor - Three Trailers

Yes

Type of Equipment

Van

Tank

Flat

Dump

Refer

Approx. No. of Miles (total)

Start Date

End Date

Motorcoach - School Bus (more than 8 passengers)

Yes

Approx. No. of Miles (total)

Start Date

End Date

Motorcoach - School Bus (more than 15 passengers)

Yes

Approx. No. of Miles (total)

Start Date

End Date

Other

Approx. No. of Miles (total)

Start Date

End Date

List states operated in for the last 5 years:

Show special courses or training that will help you as a driver:

Which safe driving awards do you hold and from whom?

EXPERIENCE & 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

Years of High School completed

Years of College completed

Name of Last School Attended

City

State

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 (typed Name)(Required)

Date(Required)

MOTOR VEHICLE DRIVER'S CERTIFICATION OF VIOLATIONS

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.

Date

Offense

Location

Type of Vehicle Operated

Date

Offense

Location

Type of Vehicle Operated

Date

Offense

Location

Type of Vehicle Operated

Date

Offense

Location

Type of Vehicle Operated

Date

Offense

Location

Type of Vehicle Operated

Date

Offense

Location

Type of Vehicle Operated

Date

Offense

Location

Type of Vehicle Operated

Date

Offense

Location

Type of Vehicle Operated

Date

Offense

Location

Type of Vehicle Operated

Date

Offense

Location

Type of Vehicle Operated

Date

Offense

Location

Type of Vehicle Operated

Date

Offense

Location

Type of Vehicle Operated

Date

Offense

Location

Type of Vehicle Operated

Date

Offense

Location

Type of Vehicle Operated

Date

Offense

Location

Type of Vehicle Operated

Date

Offense

Location

Type of Vehicle Operated

Date

Offense

Location

Type of Vehicle Operated

Date

Offense

Location

Type of Vehicle Operated

Date

Offense

Location

Type of Vehicle Operated

Date of Certification

RELEASE OF CDL HOLDER'S REPORTED

POSITIVE ALCOHOL OR CONTROLLED

SUBSTANCE TEST RESULTS

Use this form to obtain the CDL holder's reported positive alcohol or controlled substance test results information.

This form should ONLY be used if you wish to inquire whether or not a prospective driver (CDL Holder) has had a positive alcohol or controlled substance test result reported to the Texas Department of Public Safety in compliance with state law.

THIS FORM IS NOT REQUIRED FOR REPORTING A POSITIVE ALCOHOL OR CONTROLLED SUBSTANCE TEST.

1) This form must be completed in full and include the driver's original signature.

2) Deliver, mail or FAX the completed form to: Texas Department of Public Safety

I authorize release of the CDL holder's reported positive alcohol or controlled substance test results reported under state law to Davis Iron Works at P.O. Box 20425, Waco, Texas 76702

Name (signature of agreement)(Required)

Drivers License Number(Required)

Drivers License State(Required)

Date of Birth(Required)

Address of CDL Holder(Required)

Date(Required)

REFERENCE DISCLOSURE AUTHORIZATION FORM

I hereby authorize any individual, current or former employer, educational institution, or military branch listed in my application and/or resume to disclose in good faith to Davis Iron Works or its representatives, orally or in writing, information relating to my fitness for employment including, but not limited to, job performance, reasons for termination salary, job duties, eligibility to rehire, work habits, disciplinary actions, training, education, experience, knowledge, skills, qualifications, professional conduct, evaluation information and attitude. I release these individuals and entities, and their representatives, from all liability for providing such disclosures and for any consequences that may occur as a result of those disclosures.

Name (signature of agreement)(Required)

Date(Required)

DRIVER STATEMENT OF ON-DUTY HOURS

INSTRUCTIONS: Motor carriers when using a driver for the first time shall obtain from the driver a signed statement giving the total time on-duty during the immediately preceding 7 days and time at which such driver was last relieved from duty prior to beginning work for such carrier. Rule 395.8(j)(2) Federal Motor Carrier Safety Regulations. NOTE: Hours for any compensated work during the preceding 7 days, including work for a non-motor carrier entity, must be recorded on this form.

Date

Hours Worked

Date

Hours Worked

Date

Hours Worked

Date

Hours Worked

Date

Hours Worked

Date

Hours Worked

Date

Hours Worked

Total Hours Worked

I hereby certify that the information given above is correct to the best of my knowledge and belief, and that I was last relieved from work at

Time

Date Relieved from Work

Name (signature of agreement)(Required)

Date Signed(Required)

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 non-motor carrier entity.

Are you currently working for another employer?

Yes

At this time do you intend to work for another employer while still employed by this company?

Yes

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.

Name (signature of agreement)(Required)

Date Signed Page(Required)

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 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:

Driver's License No.(Required)

Drivers License State(Required)

Drivers License Expiration Date(Required)

Drivers License Class(Required)

Endorsement(s)

Restriction(s)

Type of License

DRIVER CERTIFICATION: I certify that I have read and understood the above requirements.

Name (signature of agreement)(Required)

Date(Required)

Notes:

DISCLOSURE AND AUTHORIZATION FOR CONSUMER AND/OR INVESTIGATIVE CONSUMER REPORT

In connection with your application and/or employment with above listed Davis Iron Works (hereinafter "Company") this notice is provided to inform you that a "consumer report" and/or "investigative consumer report" , as defines by the Fair Credit Reporting Act (15 U.S.C. section 1681), may be obtained from a consumer reporting agency for employment purposes. These reports may include information about your character, general reputation, personal characteristics and mode of living, whichever are applicable. The report may also contain information about you relating to criminal history, credit history, motor vehicle records such as driving records, social security verification, worker's compensation claims (post job offer or conditional job offer), verification of education or employment history or other background checks. They may involve personal interviews with sources such as your neighbors, friends or associates. You have the right, upon written request made within a reasonable time after receipt of this notice, to request disclosure of the nature and scope of any investigative consumer report to National Crime Search, Inc., 3452 E. Joyce Blvd., Fayetteville, AR 72703 - 888-527-3282. For information about National Crime Search, Inc.'s privacy practices see www.nationalcrimesearch.com. The scope of this notice and authorization is not limited to the present and, if you are hired, will continue and allow Company to conduct future background screenings for retention, promotion or reassignment, unless revoked by you in writing. Company also reserves the right to share your report with any third-party for whom you will be placed to work with as a representative of Company.

ACKNOWLEDGEMENT AND AUTHORIZATION

By signing below you acknowledge receipt of a copy of the A Summary of Your Rights under the Fair Credit Reporting Act and certify that you have read this notice and authorization as well as the summary document. You hereby authorize the obtaining of a consumer report and/or investigative consumer report at any time after the receipt of this authorization by Company, and if you are hired, throughout your employment, as permitted by law. You also confirm your understanding and provide consent for this report to be shared with a third-party for whom you may be placed to work as a representative of Company, if applicable.

Name (signature of agreement)(Required)

Date(Required)

Full Legal Name(Required)

Other or Former Names

Name on Drivers License(Required)

County of Residence(Required)

GENERAL CONSENT FOR LIMITED QUERIES OF THE FEDERAL MOTOR CARRIER SAFETY ADMINISTRATION (FMCSA) DRUG AND ALCOHOL CLEARINGHOUSE

I hereby provide consent to Steel and Pipe Supply Company, Inc. to conduct a limited query of the FMCSA Commercial Driver’s License Drug and Alcohol Clearinghouse. (Clearinghouse) to determine whether drug or alcohol violation information about me exists in the Clearinghouse. This consent form will be placed in the drivers qualification file and will act as consent for any future query(s) to be conducted while at the employment of the above listed company. I understand that if the limited query conducted by Steel and Pipe Supply Company, Inc. indicates that drug or alcohol violation information about me exists in the Clearinghouse, FMCSA will not disclose that information to Steel and Pipe Supply Company, Inc. without first obtaining additional specific consent from me. I further understand that if I refuse to provide consent for Steel and Pipe Supply Company, Inc. to conduct a limited query of the Clearinghouse, Steel and Pipe Supply Company, Inc. must prohibit me from performing safety sensitive functions, including driving a commercial motor vehicle, as required by FMCSA’s drug and alcohol program regulations.

Name (signature of consent)(Required)

Date(Required)

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