Apply to Reveille Trucking

DRUG AND/OR ALCOHOL TESTING CONSENT FORM

EMPLOYEE/OWNER OPERATOR AGREEMENT AND CONSENT

TO DRUG AND/OR ALCOHOL TESTING

I hereby agree, upon a request made under the drug/alcohol testing policy of Reveille Trucking to submit to a drug or alcohol test and to furnish a sample of my urine, breath, and/or blood for analysis. I understand and agree that if I at any time refuse to submit to a drug or alcohol test under company policy, or if I otherwise fail to cooperate with the testing procedures, I will be subject to immediate termination. I further authorize and give full permission to Reveille Trucking and or its company physician to send the specimen or specimens so collected to a laboratory for a screening test for the presence of any prohibited substances under the policy, and for the laboratory or other testing facility to release and all documentation relating to such test to Reveille Trucking and/or to any governmental entity involved in a legal proceeding or investigation connected with the test. Finally, I authorize Reveille Trucking to disclose any documentation relating to such test to any governmental entity involved in a legal proceeding or investigation connected with the test.

I will hold harmless Reveille Trucking , its company physician and any testing laboratory Reveille Trucking might use, meaning that I will not sue or hold responsible such parties for any alleged harm to me that might result from such testing, including loss of employment or any kind of adverse job action that might arise as a result of drug or alcohol test, even if a company or laboratory representative makes an error in the administration or analysis of the test or the reporting of the results. I will further hold harmless Reveille Trucking, it's company physician, and any testing laboratory Reveille Trucking might use for any alleged harm to me that might result from the release or use of information or documentation relating to the drug or alcohol test as long as the release or use of the information is within the scope of this policy and the procedures as explained in the paragraph above.

Reveille Trucking, Inc has a zero tolerance stance on any abuse or negligence on your part of not adhering to these rules, regulations and laws.

This policy and authorization have been explained to me in a language I understand, and I have been told that if I have any questions about the test or the policy they will be answered.

I UNDERSTAND THAT Reveille Trucking WILL REUIRE A DRUG SCREEN TEST UNDER THIS POLICY WHENEVER I AM INVOLVED IN AN ON THE JOB ACCIDENT OR INJURY UNDER CIRCUMSTANCES THAT SUGGEST POSSIBLE INVOLVEMENT OR INFLUENCE OF DRUGS OR ALCOHOL IN THE ACCIDENT OR INJURY EVENT.

Signature: _______________      Date: ________________

Name (print): _____________________________      Recruiter Signature: ________________

IMPORTANT DISCLOSURE

REGARDING BACKGROUND REPORTS FROM THE PSP Online Service

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

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

When the application for employment is submitted by mail, telephone, computer, or other similar means, if the Prospective Employer uses any information it obtains from FMCSA in a decision to not hire you or to make any other adverse employment decision regarding you, the Prospective Employer must provide you within three business days of taking adverse action oral, written or electronic notification: that adverse action has been taken based in whole or in part on information obtained from FMCSA; the name, address, and the toll free telephone number 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 Reveille Trucking (“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 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): _____________________________

NOTICE: This form is made available to monthly account holders by NIC on behalf of the U.S. Department of Transportation, Federal Motor Carrier Safety Administration (FMCSA). Account holders are required by federal law to obtain an Applicant’s written or electronic consent prior to accessing the Applicant’s PSP report. Further, account holders are required by FMCSA to use the language contained in this Disclosure and Authorization form to obtain an Applicant’s consent. The language must be used in whole, exactly as provided. Further, the language on this form must exist as one stand-alone document. The language may NOT be included with other consent forms or any other language.

NOTICE: The prospective employment concept referenced in this form contemplates the definition of “employee” contained at 49 C.F.R. 383.5.

Instructions

Applicant: Complete Section 1.
Previous Employer: Complete sections 2 and 3.
Prospective Employer: Complete sections 4 and 5.

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Section 1: Authorization

I (applicant name) __________________________________________ hereby authorize:

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Section 2: Accident History

The applicant named above was employed by us Yes No
Employed as ______________________________
from (mm/yy) _________________ to (mm/yy) _____________________

Did they drive a motor vehicle for you? Yes No

if yes, check what type:
Straight Truck Tractor/Semitrailer Bus
Cargo Tank Doubles/Triples Other (specify) _________________

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

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Section 3: Accident History

Please check the box for any statements that apply.

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Section 4: Form Transmission

This form was sent to previous employer via Fax Mail Email Other
By:______________________ Date: ____________________

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Section 5: Form Receipt

To former employer: please provide the following information about this applicant. This applicant has submitted a waiver of any liability claim against you for providing this inquiry - please see the bottom of this page.

• Name of applicant: ________________
• SSN of applicant:   _________________
• Date of birth:   ___________________
• Employment Dates: ________________

1. Are the dates of employment provided correct? ___________________
2. If not, when was this applicant employed by you? _________________
3. Was the applicant's conduct satisfactory? ________________________
4. What kind of work did this applicant do?__________________________
5. What equipment did this applicant operate? _____________________
6. How many accidents did this applicant have? _____
               How many were preventable? _____
7. Why did this applicant leave your business? (circle)
    Discharged   Laid Off   Resigned
8. Is this applicant elligible for rehire? ___________
9. Do you have any other remarks about this applicant?
   ______________________________________________________________________
   ______________________________________________________________________
   ______________________________________________________________________


10. Signature _____________________________ Date: ______ /_____ /______

Release

Former Employer: __________________   Date: ______ /_____ /______

I hereby authorize the above-named employer to release any and all information concerning my accident record, performance, conduct, and all DOT required substance use disclosures required under Federal Motor Carrier Safety Regulations, Part 391.23, while in their employ. Further, I release these employers from any and all liability resulting from furnishing this information.

Applicant Signature: _______________________   Date: ______ /_____ /______