Annual Review of Driving Record
Motor Carrier Instructions: Each motor carrier shall at least once every 12 months, require each driver to prepare and furnish it with a list of all violations of
motor vehicle traffic laws and ordinances (other than parking) of which the driver has been convicted, or on account of which he/she has forfeited bond or collateral
during the preceding 12 months (§391.27). Drivers who have provided information required by §383.31 need not repeat that information on this form.
Driver Requirements: Each driver shall furnish the list as required by the motor carrier above. If the driver has not been convicted of, or forfeited bond or
collateral on account of any violation which must be listed, he/she shall so certify (§391.27).
Completed by Driver – Certification of Violations
Driver’s Printed Name
Social Security Number
Hire Date
DL Number
State
Exp Date
I certify that the following is a true and complete list of traffic violations required to be listed for which I have
been convicted or forfeited bond or collateral during the past 12 months.
If you have had NO violations, please indicate by writing NONE
Date
Date of Certification
Offense
Location
Type of Vehicle
Driver’s Signature
Completed by Motor Carrier – Annual Review of Driving Record
I have hereby reviewed the driving record of the above named driver in accordance with §391.25 and find that
he/she (check one):
Meets minimum requirements of safe driving.
Does not adequately meet satisfactory safe driving performance.
Is disqualified to drive a motor vehicle pursuant to §391.15.
Action Taken
With Driver
Reviewed By (Print)
Date
Signature
Title
MVR Annual Review
11/07/12
STARTING THE BACKGROUND SCREENING PROCESS
Rexus Corporation’s national headquarters is in Charlotte, North Carolina.
To ensure best results, the client shares information with Rexus following the
procedure below:
• We recommend that you contact Rexus before beginning to discuss which
background investigations are best for your company.
• To start the process, fax or e-mail:
Job application
Resume (if available)
Signed Disclosure and Release form
Work Request form
to Rexus at 888.899.0394 or to [email protected].
Online services for submission are also available.
• When Rexus completes the work, we will return a report to you as soon as
possible by e-mail, fax, or regular mail, based on your preference. We encrypt
all incoming and outgoing information and send documents in PDF format.
You can also retrieve reports online via secure portal access.
• Rexus needs your contact person’s telephone number, fax number, and
e-mail address so that we know where to direct information. We recommend
e-mail when possible.
• Are there any special instructions? For example, does Rexus need to call the
contact person before sending reports, or can we send reports when complete?
• If you have applications which will be sent from multiple locations, please let
us know so that Rexus can inform your key people with details of the process.
For any questions concerning start-up procedures, please contact Billy
Ensley, Chief Operating Officer, at 800.588.4119 or [email protected].
BACKGROUND SCREENING WORK REQUEST
Client: Name: Savanna Well Servicing
Site: Dickinson, ND
Contact: Coley Hueske
Phone Number: 701-483-5488
Fax Number: 701-483-5490
E-mail Address: [email protected]
Applicant Name: ______________________________________________________________
Position Applied For: _______________________________ Location/Code: _______________
Search items requested for this applicant:
National Bankruptcy Search
Business References
Civil Records
Education Verification
Employment Verification
Federal Criminal Records—Circle: National or One district
Motor Vehicle Records
Municipal (County) Criminal Records—Felonies and Misdemeanors
Social Security Number Verification
Personal Credit Report
Personal References
Professional Licenses and Certifications Verification
Statewide Repository Criminal Records—Felonies and Misdemeanors
Sexual Predators Registry
10-Panel Drug Screening
Office of Foreign Assets Control—OFAC (National Terrorists Watch Lists
Search)—Free to all clients
Please e-mail or fax this request to 888.899.0394 or call 800.588.4119.
DISCLOSURE AND RELEASE
In connection with my application for employment with Savanna Energy Services, I understand
that a background report may be requested at will by Savanna Energy Services. This report
may include such information as: education, former employment, driving record, credit,
bankruptcy proceedings, criminal records, etc., from federal, state, and other agencies which
maintain such records.
As set forth in the Fair Credit Reporting Act, I have the right to request from Savanna Energy
Services, and the report provider, upon proper identification, the nature and substance of the
information obtained from the background report.
I authorize any party or agency contacted by Savanna Energy Services or its authorized
representatives, to furnish the above-described information. I hereby authorize procurement of
the background report.
__
Applicant Signature
Date
Name (Please Print)
Applicant: Please complete the following for proper identification purposes.
Name:
Last
Social Security Number
First
Middle
Maiden
Date of Birth
______________________________________________________________________________
List all other last names or maiden names used
CONTINUED ON NEXT PAGE
(CONTINUED)
Applicant Name: __________________________________
List ALL addresses for past 10 years:
Current Address:
City
County
State
Zip
How Long?
Previous Address:
City
County
State
Zip
How Long?
Previous Address:
City
County
State
Zip
How Long?
Previous Address:
City
County
State
Zip
How Long?
Previous Address:
City
County
State
Zip
How Long?
Previous Address:
City
County
State
Zip
How Long?
Driver's License Number and State
List any other names or Social Security Numbers you have used.
List any criminal convictions.
Provide the date(s), county/parish, and state.
Safety Performance History Records Request
Part 1
To Be Completed By Prospective Employee
I,________________________________________________________ ___________________ __________
First
M.I.
Last
Social Security Number
DOB
Hereby authorize:
Previous Employer
Email
Street Address
Phone
City, State, Zip
Fax
To release and forward the information requested by Part 3 of this document concerning my Alcohol and
Controlled Substances records within the previous 3 years from: Application Date
To:
Prospective Employer
Attention
Savanna Well Servicing
Street Address
Phone
3056 HWY 22
701-483-5488
City, State, Zip
Fax
Dickinson, ND 58601
701-483-5490
Email Address
In compliance with §40.25(g) and §391.23(h), release of this information must be made in a written form that
ensures confidentiality, such as a fax, email or letter.
Applicant Signature
Date
Part 2
To Be Completed By Previous Employer
Accident History
The applicant named above was employed by us
Position
From (mm/yy)
Did he/she drive a motor vehicle
Yes
No If yes, type?
Cargo Tank
Doubles/Triples
Other
Yes
Strait Truck
No
To (mm/yy)
Tractor – Semitrailer
Bus
(Specify
Other)
Reason for leaving your employ
Discharged
Resignation
Lay Off
Military Duty
If there is no safety performance history to report, check none, sign below and return
None
Accidents: Complete the following for any accidents included on your accident register that involved the
applicant in the 3 years prior to the application date shown above or check none
None
Date
Location
# Injuries
# Fatalities
Hazmat Spill
Please provide information concerning any other accidents involving the applicant that were reported to
government agencies or insurers or retained under internal company policies:
Any other remarks:
Signature
Part 3
Title
Date
To Be Completed By Previous Employer
Drug and Alcohol History
If the driver was not subject to DOT testing requirements while employed by you, please fill in the dates of
employment, complete the bottom of Part 3, sign and return. From (mm/yy)
To (mm/yy)
1
Safety History Request
11/07/12
Safety Performance History Records Request
Part 3 (cont)
To Be Completed By Previous Employer
Drug and Alcohol History
Driver was subject to DOT testing requirements
From (mm/yy)
To (mm/yy)
1) Has this person had an alcohol test with the result of 0.04 or higher alcohol concentration?
Yes
No
2) Has this person tested positive, adulterated or substituted a test specimen for controlled substances?
Yes
No
3) Has this person refused to submit to a post-accident, random, reasonable suspicion, or follow up alcohol or
controlled substance test?
Yes
No
4) Has the person committed other violations of Subpart B or Part 382, or Part 40?
Yes
No
5) If this person has violated a DOT drug and alcohol regulation, did this person complete a SAP-prescribed
rehabilitation program in your employ, including return-to-duty and follow-up tests? If yes, please send
documentation back with this form.
Yes
No
6) For a driver who successfully completed a SAP’s rehabilitation referral and remained in your employ, did
this driver subsequently have an alcohol test result of 0.04 or greater, a verified positive drug test, or refuse to
be tested?
Not Applicable
Yes
No
In answering these questions, include any required DOT drug or alcohol testing information obtained from prior
previous employers in the previous 3 years prior to the application date shown on page 1.
Company Name
Street Address
Phone
City, State, Zip
Date
Completed By (Print)
Signature
Part 4a
This form was
By
To Be Completed By Prospective Employer
Faxed to Previous Employer
Mailed
Emailed
Other (Specify)
Date
Part 4b
To Be Completed By Prospective Employer
To be completed when information is obtained.
Information received from
Recorded by
Method
Faxed from Previous Employer
Date
Mailed
Emailed
Other (Specify)
Instructions to complete the safety performance history records request
Part 1: Prospective Employee
Complete the Required Information
Sign and Date
Submit to the Prospective Employer
Part 2: Prospective Employer
Complete the Required Information
Send to Previous Employer
Part 3: Previous Employer
Complete the Required Information
Sign and Date
Return to Prospective Employer
Part 4: Prospective Employer
Complete the Required Information
Retain the Form
2
Safety History Request
11/07/12
DRIVER’S APPLICATION
FOR EMPLOYMENT
Applicant Name
(print)
Date of Application
Company
Address
City
State
Zip
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.
Signature
Date
FOR COMPANY USE
PROCESS RECORD
APPLICANT HIRED
REJECTED
DATE EMPLOYED
POINT EMPLOYED
DEPARTMENT
CLASSIFICATION
(IF REJECTED, SUMMARY REPORT OF REASONS SHOULD BE PLACED IN FILE)
SIGNATURE OF INTERVIEWING OFFICER
TERMINATION OF EMPLOYMENT
DATE TERMINATED
DISMISSED
DEPARTMENT RELEASED FROM
VOLUNTARILY QUIT
TERMINATION REPORT PLACED IN FILE
OTHER
SUPERVISOR
This form is made available with the understanding that J. J. Keller & Associates, Inc. is not engaged in rendering legal, accounting, or other professional services.
J. J. Keller & Associates, Inc. assumes no responsibility for the use of this form, or any decision made by an employer which may violate local, state, or federal law.
© Copyright 2005 J. J. KELLER & ASSOCIATES, INC., Neenah, WI • USA
(800) 327-6868 • www.jjkeller.com • Printed in the United States
15F (Rev. 2/05) 691
APPLICANT TO COMPLETE
(answer all questions - please print)
Position(s) Applied for
Name
Social Security No.
Last
First
Middle
List your addresses of residency for the past 3 years.
Current Address
Street
City
Phone
Previous
Addresses
State
How Long?
Zip Code
yr./mo.
How Long?
Street
City
State & Zip Code
Street
City
State & Zip Code
Street
City
State & Zip Code
yr./mo.
How Long?
yr./mo.
How Long?
yr./mo.
Do you have the legal right to work in the United States?
/
Date of Birth
(Required for Commercial Drivers)
/
Can you provide proof of age?
Have you worked for this company before?
Dates: From
Where?
To
Rate of Pay
Position
Reason for leaving
Are you now employed?
If not, how long since leaving last employment?
Who referred you?
Rate of pay expected
Have you ever been bonded?
Name of bonding company
(Answer only if a job requirement)
Have you ever been convicted of a felony?
If yes, please explain fully on a separate sheet of paper. 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
attached job description]?
If yes, explain 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. Add another sheet as necessary.)
EMPLOYER
DATE
FROM
MO.
YR.
POSITION HELD
NAME
ADDRESS
CITY
CONTACT PERSON
STATE
ZIP
PHONE NUMBER
TO
MO.
YR.
SALARY/WAGE
REASON FOR LEAVING
WERE YOU SUBJECT TO THE FMCSRs✝ WHILE EMPLOYED? □ YES □ NO
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 □ NO
PAGE 2 15F (Rev. 2/05) 691
EMPLOYMENT HISTORY (continued)
EMPLOYER
DATE
FROM
MO.
YR.
POSITION HELD
NAME
ADDRESS
CITY
STATE
CONTACT PERSON
ZIP
PHONE NUMBER
TO
MO.
YR.
SALARY/WAGE
REASON FOR LEAVING
WERE YOU SUBJECT TO THE FMCSRs✝ WHILE EMPLOYED? □ YES □ NO
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 □ NO
EMPLOYER
DATE
FROM
MO.
YR.
POSITION HELD
NAME
ADDRESS
CITY
STATE
CONTACT PERSON
ZIP
PHONE NUMBER
TO
MO.
YR.
SALARY/WAGE
REASON FOR LEAVING
WERE YOU SUBJECT TO THE FMCSRs✝ WHILE EMPLOYED? □ YES □ NO
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 □ NO
EMPLOYER
DATE
FROM
MO.
YR.
POSITION HELD
NAME
ADDRESS
CITY
STATE
CONTACT PERSON
ZIP
PHONE NUMBER
TO
MO.
YR.
SALARY/WAGE
REASON FOR LEAVING
WERE YOU SUBJECT TO THE FMCSRs✝ WHILE EMPLOYED? □ YES □ NO
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 □ NO
EMPLOYER
DATE
FROM
MO.
YR.
POSITION HELD
NAME
ADDRESS
CITY
STATE
CONTACT PERSON
ZIP
PHONE NUMBER
TO
MO.
YR.
SALARY/WAGE
REASON FOR LEAVING
WERE YOU SUBJECT TO THE FMCSRs✝ WHILE EMPLOYED? □ YES □ NO
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 □ NO
EMPLOYER
DATE
FROM
MO.
YR.
POSITION HELD
NAME
ADDRESS
CITY
CONTACT PERSON
STATE
ZIP
PHONE NUMBER
TO
MO.
YR.
SALARY/WAGE
REASON FOR LEAVING
WERE YOU SUBJECT TO THE FMCSRs✝ WHILE EMPLOYED? □ YES □ NO
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 □ NO
*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 property 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.
PAGE 3 15F (Rev. 2/05) 691
ACCIDENT RECORD FOR PAST 3 YEARS OR MORE (ATTACH SHEET IF MORE SPACE IS NEEDED) IF NONE, WRITE NONE
DATES
NATURE OF ACCIDENT
FATALITIES
(HEAD-ON, REAR-END, UPSET, ETC.)
HAZARDOUS
MATERIAL SPILL
INJURIES
LAST ACCIDENT
NEXT PREVIOUS
NEXT PREVIOUS
TRAFFIC CONVICTIONS AND FORFEITURES FOR THE PAST 3 YEARS (OTHER THAN PARKING VIOLATIONS) IF NONE, WRITE NONE
LOCATION
DATE
CHARGE
PENALTY
(ATTACH SHEET IF MORE SPACE IS NEEDED)
EXPERIENCE AND QUALIFICATIONS – DRIVER
List all driver licenses or permits held in the past 3 years
STATE
LICENSE NO.
TYPE
EXPIRATION DATE
DRIVER
LICENSES
A.
Have you ever been denied a license, permit or privilege to operate a motor vehicle?
YES
NO
B.
Has any license, permit or privilege ever been suspended or revoked?
YES
NO
IF THE ANSWER TO EITHER A OR B IS YES, GIVE DETAILS
DRIVING EXPERIENCE CHECK YES OR NO
DATES
CIRCLE TYPE OF EQUIPMENT FROM (M/Y)
TO (M/Y)
CLASS OF EQUIPMENT
STRAIGHT TRUCK
□ YES □ NO
(VAN, TANK, FLAT, DUMP, REFER)
TRACTOR AND SEMI-TRAILER
□ YES □ NO
(VAN, TANK, FLAT, DUMP, REFER)
TRACTOR - TWO TRAILERS
□ YES □ NO
(VAN, TANK, FLAT, DUMP, REFER)
TRACTOR - THREE TRAILERS
□ YES □ NO
MOTORCOACH - SCHOOL BUS □ YES □ NO
MOTORCOACH - SCHOOL BUS □ YES □ NO
APPROX. NO. OF MILES
(TOTAL)
(VAN, TANK, FLAT, DUMP, REFER)
More than 8
passengers
More than 15
passengers
—
—
OTHER
LIST STATES OPERATED IN FOR LAST FIVE YEARS:
SHOW SPECIAL COURSES OR TRAINING THAT WILL HELP YOU AS A DRIVER:
WHICH SAFE DRIVING AWARDS DO YOU HOLD AND FROM WHOM?
EXPERIENCE AND 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
CIRCLE HIGHEST GRADE COMPLETED: 1 2 3 4 5 6
LAST SCHOOL ATTENDED
(NAME)
7 8
HIGH SCHOOL: 1 2
3 4
COLLEGE: 1
2
3
4
(CITY, STATE)
TO BE READ AND SIGNED BY APPLICANT
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:
PAGE 4 15F (Rev. 2/05) 691
Date:
Pre-Employment Drug Testing Policy
Federal law requires applicants to indicate whether they have previously refused to be tested or received a
positive test result on any pre-employment for any other DOT employer. Please provide this information
below. It is a federal offense to falsify this information.
I have NOT tested positive on a pre-employment drug test for any other DOT employer in the past
TWO years, nor have I refused to be tested.
Yes, I have tested positive (or refused to be tested) on a pre-employment drug test for another DOT
employer in the past TWO years. (If yes, please sign below, and do not continue.)
Print Name
Driver’s Signature
Date
Each applicant for a DOT-covered position at Savanna Well Servicing, after being notified that he/she will be
offered a job, must be drug tested, in accordance with federal regulations 49 CFR Part 382. If the test result is
positive, or if the applicant refuses to submit to a pre-employment test, the job offer will be withdrawn.
We must have a negative test result in our file before we can request or allow an employee to perform duties
within any of our safety-sensitive positions.
A positive dilute drug test will be considered to be a positive test. A negative dilute drug test (or invalid
specimen) will result in the employee being required to immediately take another test, with minimum notice.
Every applicant who provides a positive test result will have an opportunity to speak with a Medical Review
Officer about any recent use of prescription and non-prescription drugs that might explain the positive test
result.
The cost of the initial screening test and the confirmatory test will be paid by Savanna Well Servicing. Every
applicant whose test result is positive may, within 72 hours, request a re-test at his/her own expense. The re-test
will be conducted on the same sample as was provided for the initial test and must be conducted by a different
certified testing laboratory.
My signature below means that I have read this information, that I have had an opportunity to review a copy of
the Savanna Well Servicing drug and alcohol policy, and that if I am offered a position, I consent to being tested
for drugs as a condition of employment.
Print Name
Driver’s Signature
(Original to be kept in Driver Qualification File)
THIS POLICY IS NOT AN EMPLOYMENT CONTRACT OR AN OFFER OF AN EMPLOYMENT CONTRACT.
Date