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Employee Application

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

Date *

MM slash DD slash YYYY

Position applying for *

First Name *

Middle Name *

Last Name *

Phone Number *

Emergency Phone Number

*Age *

* The Age Discrimination of Employment Act of 1967 prohibits discrimination on the basis of age with respect to individuals who are at least 40 years of age.

Date of Birth *

MM slash DD slash YYYY

Physical Exam Expiration Date

MM slash DD slash YYYY

Current & Three Years Previous Address

Current Address (Street, City, State, & Zip) *

From *

MM slash DD slash YYYY

To *

MM slash DD slash YYYY

Previous Address 1 (Street, City, State, & Zip)

From

MM slash DD slash YYYY

Previous Address 2 (Street, City, State, & Zip)

From

MM slash DD slash YYYY

Previous Address 3 (Street, City, State, & Zip)

From

MM slash DD slash YYYY

Have you worked for this company before? *

Yes

If YES, give dates: From

MM slash DD slash YYYY

Reason for leaving.

Education History

Please select the Highest grade completed *

College

Post Graduate

Employment History

Give a Complete Record of all employment for the past three years, including any unemployment or self-employment, and all commercial driving experience for the past ten years.

Employer #1

From (Mo/Yr) *

To (Mo/Yr) *

Present or Last Employer Name *

Position Held *

Address (Street, City, State, & Zip) *

Reason for Leaving

Phone Number *

Were you subject to the FMCRs* while employed here? *

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

Employer #2

From (Mo/Yr)

To (Mo/Yr)

Present or Last Employer Name

Position Held

Address (Street, City, State, & Zip)

Reason for Leaving

Phone Number

Were you subject to the FMCRs* while employed here?

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

Employer #3

From (Mo/Yr)

To (Mo/Yr)

Present or Last Employer Name

Position Held

Address (Street, City, State, & Zip)

Reason for Leaving

Phone Number

Were you subject to the FMCRs* while employed here?

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

Employer #4

From (Mo/Yr)

To (Mo/Yr)

Present or Last Employer Name

Position Held

Address (Street, City, State, & Zip)

Reason for Leaving

Phone Number

Were you subject to the FMCRs* while employed here?

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

* The Federal Motor Carrier Safety Regulations (FMCRSs) apply to anyone who operates a motor vehicle on a highway in interstate commerce to transport passengers of property when the vehicle: (1) has a GVWR or weighs 10,001 pounds or more, (2) is designed or used to transport nine or more passengers, or (3) is of any size, used to transport hazardous materials in a quantity requiring placard.

Driving Experience

Class of Equipment

Straight Truck

From

MM slash DD slash YYYY

Approximate Number of Miles

Tractor & Semi-Trailer

From

MM slash DD slash YYYY

Approximate Number of Miles

Tractor-Two Trailers

From

MM slash DD slash YYYY

Approximate Number of Miles

Tractor-Three Trailers

From

MM slash DD slash YYYY

Approximate Number of Miles

Other

From

MM slash DD slash YYYY

Approximate Number of Miles

List special courses/training completed (PTD/DDC, Haz-Mat, etc.)

List any Safe Driving Awards you hold and from whom

Accident Record for the Past Three Years

Accident #1

Date of Accident

MM slash DD slash YYYY

Location of Accident

# of Fatalities

# of People Injured

Nature of Accident (Head on, rear end, upset, etc.)

Accident #2

Date of Accident

MM slash DD slash YYYY

Location of Accident

# of Fatalities

# of People Injured

Nature of Accident (Head on, rear end, upset, etc.)

Accident #3

Date of Accident

MM slash DD slash YYYY

Location of Accident

# of Fatalities

# of People Injured

Nature of Accident (Head on, rear end, upset, etc.)

Accident #4

Date of Accident

Location of Accident

# of Fatalities

# of People Injured

Nature of Accident (Head on, rear end, upset, etc.)

Traffic Convictions & Forfeitures for the Last Three Years (other than parking violations)

Conviction #1

Date

MM slash DD slash YYYY

Location

Charges

Penalty

Conviction #2

Date

MM slash DD slash YYYY

Location

Charges

Penalty

Conviction #3

Date

MM slash DD slash YYYY

Location

Charges

Penalty

Conviction #4

Date

MM slash DD slash YYYY

Location

Charges

Penalty

Conviction #5

Date

Location

Charge

Penalty

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

License #1

State

License #

Type

Endorsement

Expiration Date

MM slash DD slash YYYY

License #2

State

License #

Type

Endorsement

Expiration Date

MM slash DD slash YYYY

License #3

State

License #

Type

Endorsement

Expiration Date

MM slash DD slash YYYY

License #4

State

License #

Type

Endorsement

Expiration Date

MM slash DD slash YYYY

License #5

State

License #

Type

Endorsement

Expiration Date

A. Have you ever been denied a license, permit or privilege to operate a motor vehicle? *

Yes

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

Yes

C. Is there any reason you might be unable to perform the functions of the job for which you have applied (as described in the job description)? *

Yes

D. Have you ever been convicted of a felony? *

Yes

If the answer to A, B, or C is “YES”, give details

Personal References

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

Name *

Address *

Phone *

Name

Address

Phone

Name

Address

Phone

To Be Read and Signed by Applicant

If is agreed and understood that any misrepresentation given on this application shall be considered an act of dishonesty. It is agreed an understood that the motor carrier or his agents may investigate the applicant’s background to ascertain any and all information of concern to applicant’s record, whether same is of record or not, and applicant released employers and person’s name herein from all liability for any damages on account of his furnishing such information. It is also agreed and understood that under the Fair Credit Reporting Act, Public Law 91-508, I have been told that his investigation may include an investigating Consumer Report, including information regarding my character, general reputation, personal characteristics, and mode of living. I agree of furnish such additional information and complete such examinations as may be required to completed may application file. If is agreed and understood that this Application for Qualification in no way obligates the motor carrier to employed or hire the application. It is agreed and understood that if qualified and hired, I may be on a probationary period during which time I may be disqualified without recourse. This certifies that this application was completed by me, and that all entries on it and information in it are true and completed to the best of my knowledge.

Please enter your full name in this field, as it appears on your drivers license. By entering your name, this acts as your signature and agreement of terms. *

Date *

MM slash DD slash YYYY

THE BELOW DISCLOSURE AND AUTHORIZATION LANGUAGE IS FOR MANDATORY USE BY ALL ACCOUNT HOLDERS

IMPORTANT DISCLOSURE
REGARDING BACKGROUND REPORTS FROM THE PSP Online Service

In connection with your application for employment with Ragar Transportation, LTD (“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 Data’s 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 Ragar Transportation, LTD (“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 Data’s 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.

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

Please enter your full name in this field, as it appears on your drivers license. By entering your name, this acts as your signature and agreement of terms. *

Date *

MM slash DD slash YYYY

Full Name *

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

DRIVER'S RIGHTS PERTAINING TO RELEASE OF DRIVER INFORMATION UNDER REGULATION 391.23

Motor carriers have the responsibility to make the following investigations and inquire with respect to each driver employed, other than a person who has been a regularly employed driver of the motor carrier for a continuous period which began before January 1, 1971.

(a)(1) An inquiry into the driver’s driving record during the preceding three years to the appropriate agency of every State in which the carver held a motor vehicle operator’s license or permit during those three years; and
(a)(2) An investigation of the driver’s employment record during the preceding three years.
(b) A copy of the driver record(S) obtained in response to the inquiry or inquires to each State driven record agency as required must be placed in the Driver Qualification File within 30 days of the date the driver’s employment begins and be retained in compliance with 391.51.
(c) Replies to the investigations of the driver’s safety performance history must be placed in the Driver Investigation History File within 30 days of the date the driver’s employment begins. This goes into effect after October 29, 2004.
(d) Prospective motor carrier must investigate the information from all previous employers of the applicant the employed the driver to operate a CMV within the previously three years. This information must cover general driver identification and employment verification information, date elements as specified in 390.15 for accident involving the driver that occurred in the three-year period preceding the date of the employment application, and any accidents the previous employer may wish to provide.
(e) Prospective motor carrier must investigate the information from all previous DOT regulated employed the driver within the previous three years from the date of the employment application in a safety-sensitive function that required alcohol and controlled substance testing specified by 49 CFR Part 40.

Drivers have the following rights:

The right to review information provided by pervious employers.
The right to have errors in the information corrected by the previous employers and for that previous employer to re-send the corrected information to the prospective employer.
The right to have a rebuttal statement attached to the alleged erroneous information, if the previous employer and the driver cannot agree on the accuracy of the information.

Drivers who wish to review previous employer-provided investigative information must submit a written request to the prospective employer when applying or as late as 30 days after employed or being notified of denial of employment. The prospective employer must provide this information to the applicant within five business days of the receiving the written request. If the driver has not arranged to pick up or receive the requested record within 30 days of the prospective employer making them available making them available, the prospective motor carrier may consider the driver to have waiver his/her requested to review the record.

Drivers wishing to request correction of erroneous information in records must send the requested for the correction to the previous employer that provides the record. After October 29, 2004, the previous employer must either correct and forward the information to the prospective motor carrier employer or notify the driver within 15 days of receiving the driver’s request to correct the data that it does not agree to correct the data. Driver wishing to rebut information in record must send the rebuttal to the previous employer with instructions to include the rebuttal in the driver’s Safety Performance History.

I acknowledge that I have read and understand the contents of this document

Please enter your full name in this field, as it appears on your drivers license. By entering your name, this acts as your signature and agreement of terms. *

Date *

MM slash DD slash YYYY

Full Name *

AUTHORIZATION AND RELEASE TO OBTAIN INFORMATION

Under the Fair Credit Reporting Act (“FCRA”), 15 U.S.C. § 1681 et seq., the regulations applicable to the Federal Department of Transportation’s Federal Motor Carriers Safety Administration, including 49 CFR § 40.329, the Americans with Disabilities Act and all other applicable federal, state, and local laws, I hereby authorize and permit

Ragar Transportation, LTD. 827 Nafta Blvd. Unit B. Laredo, TX 78045
(Name of Employer or Prospective Employer)

to obtain information, where permitted, pertaining to my employment records, driving history records, driving performance and safety history, criminal history, credit history, civil records, workers’ compensation (post-offer only), alcohol and drug testing, verification of my academic and/or professional credentials, and information and/or copies of documents from any military service records.

I understand that an “investigative consumer report” may result that could include information as to my character, general reputation, personal characteristics, and mode of living that may be obtained by interviews with individuals with whom I am acquainted or who may have knowledge concerning any such items of information. I specifically authorize the release of information by my former employers for the purpose of satisfying driver qualification regulations.

DOT Drivers. I understand that Title 49 of the Federal Code of Regulations, § 391.23, requires that my prospective employer and/or its agent(s) may contact all former employers of a driver within the last three years under the regulation of the Department of Transportation. Information such as dates of employment, position, accident history, as well as information pertaining to my drug and alcohol testing history, may be requested from each employer in accordance with Section 391.23 and 49 CFR 40.25.

By signing below, I consent to and authorize the gathering of this information by my prospective employer and those whom my prospective employer has engaged to request and obtain this information, including from former employers and/or from or through iiX. I hereby release and hold harmless any person, firm, or entity, including iiX, that discloses matters in accordance with this authorization from liability that might otherwise result from the request for use of and/or disclosure of any or all of the information discussed above. This information may be obtained in whole or in part by iiX or its agents.

I consent to and authorize the processing of my information in a foreign country by persons providing services to my prospective employer and understand that this information may be accessible to law enforcement and national security authorities of that jurisdiction.

I understand and acknowledge that this release of information may assist my prospective employer to make a determination regarding my suitability as an employee. I further understand that under the FCRA, I may request a copy of any consumer report from the consumer reporting agency that compiled the report, after I have provided proper identification. I agree that a copy of this authorization has the same effect as an original. Where permitted, this authorization shall remain in effect over the course of my employment and reports may be ordered periodically during the course of my employment.

Please enter your full name in this field, as it appears on your drivers license. By entering your name, this acts as your signature and agreement of terms. *

Date *

MM slash DD slash YYYY

Full Name *

DRIVER APPLICANT DRUG AND ALCOHOL PRE-EMPLOYMENT STATEMENT

CFR Part 40.25 (i) requires the employer to ask any applicant, 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 rules during the past two years. If the potential employee admits that he or she had a positive test or refusal to test, provide documentation of successful completion of the return-to duty process.

(See Section 40.25 (b) (5) and (e)).

Applicant Name *

ID Number

As an applicant, applying to perform safety-sensitive functions for our company, you are required by CFR Part 40.25 (i) 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

2. If you answered yes, to the above question, can you provide proof that you have successfully completed the DOT return-to-duty requirements? *

Yes

My signature below certifies that the information provided is true and correct.

Please enter your full name in this field, as it appears on your drivers license. By entering your name, this acts as your signature and agreement of terms. *

Date *

MM slash DD slash YYYY

General Consent Form for Limited Queries of the Federal Motor Carrier Safety Administration (FMCSA) Drug and Alcohol Clearinghouse

Name *

I hereby provide consent to Ragar Transportation, LTD 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.

I understand that if the limited query conducted by Ragar Transportation, LTD indicates that drug or alcohol violation information about me exists in the Clearinghouse, FMCSA will not disclose that information to Ragar Transportation, LTD without first obtaining additional specific consent from me.

I further understand that if I refuse to provide consent for Ragar Transportation, LTD to conduct a limited query of the Clearinghouse, Ragar Transportation, LTD must prohibit me from performing safety-sensitive functions, including driving a commercial motor vehicle, as required by FMCSA’s drug and alcohol program regulations.

I also agree that this General Consent Form in original, faxed, photocopied, or electronic (including electronically signed) form will be valid for any consumer reports or investigative consumer reports that may be requested about me, “throughout the duration of my employment”, by or on behalf of Ragar Transportation, LTD. .

Please enter your full name in this field, as it appears on your drivers license. By entering your name, this acts as your signature and agreement of terms. *

Date *

MM slash DD slash YYYY

Full Name *

CDL Number *

FORMER EMPLOYMENT VERIFICATION

Name *

Last 4 Digits of Social Security

I hereby authorize the below named organizations to release my employment work history information to Ragar Transportation, LTD. for the purpose of investigation for qualifying me to drive a commercial motor vehicle as required by the U.S. Department of Transportation & Federal Motor Carrier Safety Regulations Parts 382, 391, 392 & 49 CFR Part 40. You are hereby released from any and all liability that may results from furnishing such information. Your quick response to the request will be greatly appreciated.

List Former Employer(s)

Please enter your full name in this field, as it appears on your drivers license. By entering your name, this acts as your signature and agreement of terms. *

Date *

MM slash DD slash YYYY

Full Name *

REQUIRED DOCUMENTS

Please attach a copy of your CDL and your Medical Card. If you have trouble uploading the form, please email the form to blanca@ragar.com and include your FULL NAME and the word APPLICATION in the subject line.

STEP 3: ATTACH COPY OF YOUR CDL & MEDICAL CARD

Upload Your File *

Drop files here or

Max. file size: 80 MB, Max. files: 2.

PRINT, FILL OUT, & RETURN

Please print out the attached form, fill out all pages completely, sign, scan and upload the forms using the link below. If you have trouble uploading the form, please email the form to blanca@ragar.com and include your FULL NAME and the word APPLICATION in the subject line.

STEP 1: DOWNLOAD & PRINT THIS FORM

STEP 2: FILL OUT & SIGN ALL PAGES OF THE FORM

STEP 3: SCAN & UPLOAD THE FORM

Upload Your File *

Drop files here or

Max. file size: 80 MB, Max. files: 1.

About Ragar Transportation LTD

Employee Application

Current & Three Years Previous Address

Education History

Employment History

Driving Experience

Accident Record for the Past Three Years

Traffic Convictions & Forfeitures for the Last Three Years (other than parking violations)

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

Personal References

To Be Read and Signed by Applicant

THE BELOW DISCLOSURE AND AUTHORIZATION LANGUAGE IS FOR MANDATORY USE BY ALL ACCOUNT HOLDERS

IMPORTANT DISCLOSURE REGARDING BACKGROUND REPORTS FROM THE PSP Online Service

AUTHORIZATION

DRIVER'S RIGHTS PERTAINING TO RELEASE OF DRIVER INFORMATION UNDER REGULATION 391.23

AUTHORIZATION AND RELEASE TO OBTAIN INFORMATION

DRIVER APPLICANT DRUG AND ALCOHOL PRE-EMPLOYMENT STATEMENT

General Consent Form for Limited Queries of the Federal Motor Carrier Safety Administration (FMCSA) Drug and Alcohol Clearinghouse

FORMER EMPLOYMENT VERIFICATION

REQUIRED DOCUMENTS

PRINT, FILL OUT, & RETURN

IMPORTANT DISCLOSURE
REGARDING BACKGROUND REPORTS FROM THE PSP Online Service