APPLICATION FOR EMPLOYMENT (COMMERCIAL DRIVER)
ALL POTENTIAL EMPLOYEES ARE EVALUATED WITHOUT REGARD TO RACE, COLOR, RELIGION,
GENDER, NATIONAL ORIGIN, AGE, MARITAL OR VETERAN STATUS, THE PRESENCE OF A NON-JOB
RELATED HANDICAP OR ANY OTHER LEGALLY PROTECTED STATUS.
Raveill Trucking, Inc.
20982 Hwy 210
McGregor, MN 55760 t according to the requirements of the Federal Motor Carrier Safety Regulations and the Client Company named above.
( Must have 3 years of address listed)
Position Reason for Leaving Rate of Pay
Are you a US citizen, or otherwise authorized to work in the U.S. without any restriction? [ ] Yes [ ] No
Emergency
Contact: Relationship ______________
- Other: ( ) - Phone Number: ( ) - Work Number: ( )
Are you physically capable of heavy, manual work
Do you have any physical condition which would limit your ability to perform the job applying for? [ ] Yes [ ] No
In the past 3 years, have you lost any time from work? [ ] Yes [ ] No If yes, please explain
Would you willing to take a physical examination? [ ] Yes [ ] No

EMPLOYMENT HISTORY
ALL APPLICANTS WISHING TO DRIVER IN INTERSTATE COMMERCE MUST PROVIDE THE FOLLOWING INFORMATION ON ALL
EMPLOYERS DURING THE PRECEDING THREE YEARS. YOU MUST GIVE THE SAME INFORMATION FOR ALL EMPLOYERS FOR WHOM
YOU HAE DRIVEN A COMMERCIAL VEHICLE SEVEN YEARS PRIOR TO THE INITIAL THREE YEARS (TOTAL OF TEN YEAR
EMPLOYMENT RECORD).
Before an application is submitted, the motor carrier must inform the applicant that the information he/she provides in accordance with paragraph (b) (10) of this section may be used, and the applican previous employers will be contacted, for the purpose of investigating the applican afety performance history information as required by paragraphs (d) and (e) of 391.23
YOUR ARE REQUIRED TO LIST THE COMPLETE MAILING ADDRESS: STREET NUMBER AND NAME, CITY, STATE AND ZIP CODE
.
(Most Recent First.)
1.Employer_ Position
Dates Employed: From:_ To:_
Address
City State Zip Phone
Contact Person:_
Ending Salary Reason for Leaving
Where you subject to the Federal Motor Carrier Safety Registration while employed? [ ] Yes [__] No
Was your job designated as safety sensitive function in any DOT-Regulated mode subject to drug and alcohol testing? [__] Yes [ ] No
2.Employer_ Position
Dates Employed: From:_ To:_
Address
City State Zip Phone
Ending Salary
Contact Person:_
Reason for Leaving
Where you subject to the Federal Motor Carrier Safety Registration while employed? [ ] Yes [__] No
Was your job designated as safety sensitive function in any DOT-Regulated mode subject to drug and alcohol testing? [__] Yes [ ] No
3.Employer_ Position
Dates Employed: From:_ To:_
Address
City State Zip Phone
Contact Person:_
Ending Salary Reason for Leaving
Where you subject to the Federal Motor Carrier Safety Registration while employed? [ ] Yes [__] No
Was your job designated as safety sensitive function in any DOT-Regulated mode subject to drug and alcohol testing? [__] Yes [ ] No
4.Employer_ Position
Dates Employed: From:_ To:_
Address
City State Zip_ Phone
Ending Salary
Contact Person:_
Reason for Leaving
Where you subject to the Federal Motor Carrier Safety Registration while employed? [ ] Yes [__] No
Was your job designated as safety sensitive function in any DOT-Regulated mode subject to drug and alcohol testing? [__] Yes [ ] No
5.Employer_ Position
Dates Employed: From:_ To:_
Address
City State Zip
Ending Salary
Contact Person:_
Reason for Leaving
Where you subject to the Federal Motor Carrier Safety Registration while employed? [ ] Yes [__] No
_Phone
Was your job designated as safety sensitive function in any DOT-Regulated mode subject to drug and alcohol testing? [__] Yes [ ] No
6.Employer_ Position
Dates Employed: From:_ To:_
Address
City State Zip Phone
Ending Salary
Contact Person:_
Reason for Leaving
Where you subject to the Federal Motor Carrier Safety Registration while employed? [ ] Yes [__] No
Was your job designated as safety sensitive function in any DOT-Regulated mode subject to drug and alcohol testing? [__] Yes [ ] No
_

7.Employer_ Position
Dates Employed: From:_ To:_
Address
City State Zip Phone
Ending Salary
Contact Person:_
Reason for Leaving
Where you subject to the Federal Motor Carrier Safety Registration while employed? [ ] Yes [__] No
Was your job designated as safety sensitive function in any DOT-Regulated mode subject to drug and alcohol testing? [__] Yes [ ] No
8.Employer_ Position
Dates Employed: From:_ To:_
Address
City State Zip Phone
Contact Person:_
Ending Salary Reason for Leaving
Where you subject to the Federal Motor Carrier Safety Registration while employed? [ ] Yes [__] No
Was your job designated as safety sensitive function in any DOT-Regulated mode subject to drug and alcohol testing? [__] Yes [ ] No
9.Employer_ Position
Dates Employed: From:_ To:_
Address
City State Zip Phone
_Contact Person:_
Ending Salary Reason for Leaving
Where you subject to the Federal Motor Carrier Safety Registration while employed? [ ] Yes [__] No
Was your job designated as safety sensitive function in any DOT-Regulated mode subject to drug and alcohol testing? [__] Yes [ ] No
10.Employer_ Position
Dates Employed: From:_ To:_
Address
City State Zip Phone
Contact Person:_
Ending Salary Reason for Leaving
Where you subject to the Federal Motor Carrier Safety Registration while employed? [ ] Yes [__] No
Was your job designated as safety sensitive function in any DOT-Regulated mode subject to drug and alcohol testing? [__] Yes [ ] No
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 RESLUT IN DISCHARGE. I UNDERSTAND, ALSO, THAT I AM REQUIRED TO ABIDE BY ALL RULES AND
REGULATIONS OF THE COMPANY.
UNDERSTAND THAT INFORMATION I PROVIDE REGARDING CURRENT AND/OR PREVIOUS MAY BE USED, AND THOSE
EMPLOYER(S) WILL BE CONTACTED, FOR THE PURPOSE OF INVESTIGATIONG MY SAFETY PERFORMANCE HISTORY AS
REQUUIRED BY 49 CFR 391.23(d) AND (e). I UNDERSTAND THAT I HAVE THE RIGHT TO:
REVIEW INFORMATION PROVIDED BY CURRENT/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
I ALSO UNDERTANT THAT MISREPRESENTATION OR OMISSION OF INFORMATION OR FACTS MAY RESULT IN MY REJECTION OR
DISMISSAL. THIS CERTIFIES THAT THIS APPLCIATION WAS COMPLTED BY ME, AND THAT ALL ENTRIES ON IT AND INFORMAITON
IN IT ARE TRUE AND COMPLETE TO THE BEST OF MY KNOWLEDGE.
Applicant Signature Date
IF THIS SECTION IS NOT SIGNED & DATED BY THE APPLICANT, THE APPLICATION WILL NOT BE PROCESSED.
(i)(2) Drivers who have previous Department of Transportation regulated employment history in the preceding three years, and wish to review previous employer-provided investigative information must submit a written request to the prospective employer, which may be done at any time, including when applying, or as late as 30 days after being employed or being notified of denial of employment. The prospective employer must provide this information to the applicant within five (5) business days of receiving the written request. If the prospective employer has not yet received the requested information from the previous employer(s), then the five-business days deadline will begin when the prospective employer receives the requested safety performance history information. If the driver has not arranged to pick up or receive the requested records within thirty (30) days of the prospective employer making them available, the prospective motor carrier may consider the driver to have waived his/her request to review the records. Please contact Human Resources for more information

EXPERIENCE AND QUALIFICATIONS
APPROXIMATE NUMBER OF MILES CLASS OF EQUIPMENT TYPE OF EQUIPMENT
(
CIRCLE ALL THAT APPLY)
STRAIGHT TRUCK VAN, REEFER, TANK, FLAT
FROM
DATES
TO
TRACTOR & SEMI-TRAILER VAN, REEFER, TANK, FLAT
TRACTOR TWO TRAILERS VAN, REEFER, TANK, FLAT
OTHER: VAN, REEFER, TANK, FLAT
List states operated in for the last 5 years
Which safe driving awards do you hold and from who
Show any special courses or training that will help you as a driver
LICENSE INFORMATION
SECTION 383.21 FMCSR STATES NO PERSON WHO OPERATES A COMMERCIAL MOTOR VEHICLE SHALL AT ANY TIME HAVE MORE THAN ONE
DRIVER S LICENSE. I CERTIFY THAT I DO NOT HAVE MORE THAN ONE MOTOR VEHICLE LICENSE, THE INFORMATION FOR WHICH IS LISTED BELOW.
STATE LICENSE NUMBER EXPIRATION DATE
A. Have you ever been denied a license, permit, or privilege to operate a motor vehicle? [ ] Yes [ ] No
B. Have any license, permit, or privilege ever been suspended or revoked? [ ] Yes [ ] No
If you answered Yes to any of these questions, attach a statement explaining the details
ACCIDENT RECORD FOR PAST 5 YEARS OR MORE
If no accidents within the last 5 years, check here. [ ]
List most recent first.
Date
(Month/ Year)
Nature of Accident
(HEAD-ON, REAR-END, UPSET, ETC.)
Number of
Fatalities
Number of
Fatalities
Attach sheet if more space is needed
Hazardous Material Spill
[__] Yes
[__] Yes
[__] Yes
[__] Yes
[__] No
[__] No
[__] No
[__] No
TRAFFIC CONVICTIONS & FORFEITURES FOR THE PAST 5 YEARS
If no traffic convictions and/or forfeitures in the last 5 years, check here. [ ]
Date Convicted
(Month/Year)
Violation
(Other than violations involving parking only)
State of Violation
Attach sheet if more space is needed
Penalty
(Forfeited Bond, Collateral, and/or Points)

OTHER QUALIFICATIONS AND EXPERIENCE
List courses and training other than shown elsewhere in this application.
Show any trucking, or other experience that may help you in your work with this company.
List any other special equipment or technical materials you can work with other than those already listed.
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 RESLUT IN DISCHARGE. I UNDERSTAND, ALSO, THAT I AM REQUIRED TO ABIDE BY ALL RULES AND
REGULATIONS OF THE COMPANY.
Date Drive s Signature

COMMERCIAL DRIVER JOB FUNCTIONS
§

Documentation and Release of pre-employment testing information by driver/applicant
CFR Part 40.25(j) 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 three years. If the potential employee admits that he or she had a positive test or refusal to test, we must not use the employee to perform safety- sensitive functions, until and unless the potential employee provides documentation of successful completion of the return -to- duty process. (See Section 40.25(b)(5) and (e).
Applicant Name:
(Please Print)
Social Security Number:
As an applicant, applying to perform safety-sensitive functions for our company, you are required by CFR Part 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 three years?
[__] Yes [ ] No
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 [ ] No
If yes, please provide documentation of your successful completion of the return-to-duty process.
My signature below certifies that the information provided is true and correct.
Applicant Signature: Date:

I here b y authorize you, a DOT Regulated Employer f o r wh o m I have worked in the last 3 years , to release the following information to
Paymasters for purposes of investigation as required by Sections 391 and 382 of the Federal Motor Carrier Safety
Regulations . You are released from a n y and all liability which may result from furnishing such information . A SEPARATE FORM MUST
BE SIGNED BY THE APPLICANT F O R EACH DOT REGULATED EMPLOYER FOR WHOM THE APPLICANT HAS WORKED IN THE
LAST THREE ( 3) YEARS (FMCSR 40.
321 ).
Date: ____________Applicant’s Signature ___________________________ Applicant’s Printed Name:_____________________
Previous Employer Name: ________________________ Phone #: ______________________ Fax #:________________________
The indiv i dual n amed be l ow has app lie d to our company , or one of our client companies , for a position as a Commercial driver and states that he / she was employed by yo ur company as a(n ) _________________________ from _________ to ________________ .
We apprec i ate your time in completing , in conf i denc e , t he information requested below .
1 . Name of applicant : I
SS# :
2 . Employed from : to : as(n) :
3 .
Did he/she drive a motor veh i cle for you?
4 .
Stra i ght Truck Tractor Trailer Bus Other
If a tracto rtrailer , what type of t ra i l er? D r yvan Flatbed Reefer Hopper Dump Lowboy T anker Conta i ne r
5 . Type o f d ri ving :
Loca l R eg i ona l
OTR I
6 . Were DOT Logs Requ i red to be kept?
Yes
No
7 .
Was he/s h e an on-time and dep en dable driver?
Yes
No
No
8 .
Was his/her overall work r e c ord sat isfactory?
Yes
9 .
Reason fo r leaving you r emp l oy : Discharged ; reason Resigned Layoff
Mil i tary
10 Is he/she elig i ble for re-hire? Yes No If No , please explain
11 . Please advise of any i njur i es , il ln esses o r prescribed medications :
12 . Please adv i se of dates and de tail s of any DOT reportable accidents or tickets ( spec i fy # of i njur i es , fatal i t i es , propert y damage , hazardous sp ill s , e t c .
) :
13
14
.
15
Do you know of any reaso n wh y th i s person could not perform all the requ i red dut i es of th i s position?
Commen t s regarding sa f ety ha bit s , awards , work ethics, skills , attitude , etc _:
In the past 3 years did he/s he : test 0 .
04 or greater for alcohol? test positive for Controlled Substance? refuse to be tested while in your employ? violate any other Drug/Alcohol prohibitions?
To your knowledge fa il a drug or alcohol test for a prev i ous employer?
Yes
Yes
Yes
Yes
No
No
No
No
No
I f YES to any of the above quest i on s , please p r ovide date test was failed or refused
If Y E S t o the above , did the d ri ver f oll ow the manda t ory t reatment steps?
Person providing verification , pleas e si gn th i s form :
SIGN A TURE : TITLE : DATE:

I certify that the following is a true and complete list of traffic violations (other than parking tickets) for which I have been convicted or forfeited bond or collateral, during the past 12 months.
Date Offense Location Type of Vehicle Operated
If no violations are listed above, I certify that I have not been convicted or forfeited bond or collateral on account of any violation required to be listed according to Part 391.27 of the Federal Motor Carrier Safety Regulations during the past 12 months.
Signature Date Drive s Printed Name
Raveill Trucking, Inc.
20982 Hwy 210
McGregor, MN 55760
This day I reviewed the driving record of the above named driver in accordance with Part 391.27 of the Federal Motor
Carrier Safety Regulations. I considered any evidence that the driver has violated applicable provisions of the Federal Motor
Carrier Safety Regulations. I considered the drive s accident record and any evidence that he/she has violated laws governing the operation of motor vehicles, and gave great weight to violations, such as speeding, reckless driving and operation under the influence of alcohol or drugs, that indicate the driver has exhibited a disregard for the safety of the public. Having done the above, I find that
[ ] the driver meets the minimum requirements for safe driving, or
[ ] the driver is disqualified to drive a motor vehicle pursuant to 391.15.
Raveill Trucking, Inc.
20982 Hwy 210
McGregor, MN 55760
Supervis s Printed Name Supervis s Signature Date

In accordance with the provisions of Section 604(b)(2)(A) of the Fair Credit Reporting Act, Public
Law 91-508, as amended by the Consumer Credit Reporting Act of 1996 (Title II, Subtitle D,
Chapter I, of Public Law 104-208), you are being informed that reports verifying your previous employment, previous drug and alcohol test results, and your driving record may be obtained on you for employment purposes. These reports are required by Sections 382.413, 391.23, and 391.25 of the Federal Motor Carrier Safety Regulations.
Driver Signature
Print Name
Date
Social Security Number
Driver License #
Issuing State
Expiration Date of License Date of Birth

Return To Work Statement
Paymasters, Inc. and Raveill Trucking, Inc.believe employees are the most important assets of our company. We are committed to assisting our injured employee return to work as soon as medically appropriate and to work with the medical community to help the injured employees regain their livelihood.
The focus of our Return to Work (RTW) program is to meet the needs of Paymasters,
Inc., Raveill Trucking, Inc., and our injured employees by modifying the employee existing position and/or work schedule. The first option for transitional work is always the worksite employer. However, there are instances when that is not possible. In that case, Paymasters, Inc. will work at coordinating other transitional assignments within the same community as the worksite employer or within reasonable distance of the injured employee ace of residence.
For this program to be successful the injured employee must report all injuries to
Paymasters, Inc. Human Resources Department on the same day of the incident. We will provide our injured employees with information about our RTW program and other materials that can be presented to the treating medical provider so a temporary transitional duty assignment can be designed as soon as possible.
Everyone should be alert for potential accidents and strive to eliminate them. If you are aware of an unsafe condition, it should be reported immediately to your supervisor to be addressed. This action may prevent an injury from occurring. If an injury does occur, it must be reported immediately to a supervisor whether or not you plan to seek immediate medical attention for the injury.
Thank you and please remember most injuries can be prevented.
I have read and agree to participate in the RTW program if I am involved in an on the job injury that prevents me from working my regular duties.
Employee Signature: Date:

ACKNOWLEDGMENT AND AUTHORIZATION FOR CO-EMPLOYMENT
I certify that answers given herein are true and complete to the best of my knowledge.
Paymasters, Inc. is proud to have entered into a co-employer relationship with our Raveill Trucking, Inc.thereafter referred to as worksite employer ). With the co-employer relationship, Paymasters, Inc. and the worksite employer divide the employer responsibilities through our subscriber agreement. Paymasters, Inc. becomes the employer of record for payroll tax purposes, filing paperwork, administration of payroll, employee benefits, personnel systems and records. While the worksite employer continues to direct the employees day-to-day activities. All references to ompany are intended to include both
Paymasters, Inc. and the worksite employer.
I authorize the Company to investigate all statements contained in this application for employment as may be necessary in arriving at an employment decision. I further agree to indemnify the Company against any and all liability that may result from making such investigation.
I hereby understand and acknowledge that, unless otherwise defined by applicable law, any employment relationship with this organization is of an at wil nature, which means that the Employee may resign at any time and the Employer may discharge Employee at any time with or without cause. It is further understood that this at wi employment relationship may not be changed by any written document or by conduct unless such change is specifically acknowledged in writing by an authorized executive of this organization.
I also acknowledge and understand that I am applying for employment with the Company, that if hired I will be an emp loyee of the Company, and as a condition of my employment with the Company, the Company has the right to transfer my services to any available position, therefore, I agree to participate in any training that may be necessary to satisfy the position. I further agree that I will abide by all the rules, regulations and policies of the Company. and that failure to do so may be caus e for termination. I further agree that in the event I am advanced any money by the Company. or any of its subscribers, and fail to make payment as agreed, the Company may deduct the amount unpaid from any wage I may have coming.
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 employer.
Date: Applicant Signature:
Print Name:

Direct Deposit Authorization Form
*Please note that it is not necessary to fill out a form if you have done so in the past, unless you are requesting a change of account information or you are requesting to cancel your direct deposit agreement. You are not required to submit a new form each plan year.
Social Security Number or Employee I.D. Number:
Last Name:
Street Address:
First Name:
City:
Daytime Phone Number and Extension:
State: Zip Code:
Email Address:
Bank Name
Bank Phone Number
Bank Address Bank City
Please indicate the type of agreement being authorized by placing an next to the appropriate field:
State Zip
Nine Digit Routing Number (ABA Number)
New Authorization
Authorization
Change of Account Information Cancel
Account Number Type of Account
Checking
I wish to receive my payments by Direct Deposit and, by including my email address, I acknowledge that all correspondence reg arding account balances and reimbursements will be made electronically. I hereby authorize Paymasters, Inc. to originate electronic credit transactions to my bank
(or credit union or savings & loan) account indicated below and to credit the same to such account. I f necessary, Paymasters, Inc. may make deductions from my account for any payments credited to my account in error. This authority is to remain in full force and effect until Paymasters, Inc. has received written notification from me of its termination in such time as to afford Paymasters, Inc. and my bank a reasonable opportunity to act. I understand that claims submitted with change will be delayed two business days while Paymasters, Inc. completes a zero dollar transaction with my financial institution to confirm the validity of this account .
Savings
Signature Date
Please attach a copy of a voided check. Please do not send a deposit slip as sometimes the routing numbers are different from that of your checks . (Please include a copy of your voided check in the space below)

HireRight
PART 1 - DOT DRUG AND ALCOHOL RELEASE
I authorize , per 49 CFR Part 40 , the release of in formation from my DOT regulated drug and alcohol testing records by my previous employers to HireRight for the sa l e purpose of transmitting such records to PAYMASTERS and its representatives/agents/clients . I authorize the release of the fo l lowing information concerning
DOT drug and alcohol testing v i ola t ions inc l ud i ng pre-employment tests dur i ng the past three years : ( l ) alcohol tests with a result of 0.04 or h i gher ; ( ii ) verif i ed positive drug tests ; ( i i i ) refusals to be te s ted (i nc l uding verified adulterated or substituted results ); (iv) other violations of DOT drug and alcohol testing regulations ;
(v) information obtained from prev io us employers of drug and alcohol rule violat i on ( s) ; and ( vi) documents , if any , of completion of retu r n-to-duty process following a ru l e violation . I hereby aut h or i ze my worksite employer to submit copies of my current and future drug test results to PAYMASTERS . This autho r ization shall expire if and when my work sit e employer is no longer a client of PAYMASTERS . The information I have authorized HireRight to review involves tests required by the DOT . If any carr i e r/company/school for whom I was prev i ously employed furnishes HireRight with i nformation conce r n i ng items ( i ) through ( vi) above , I also authorize that carrier /c ompany/school to release and furn i sh the dates of my negative drug and/or alcohol tests w i th results below 0 .
04 during the three year period and the name and p hone number of any substance abuse professionals who evaluated me during the past three years .
PART 2 - CONSUMER REPORT DISCLOSURE AND RELEASE
I n connection with your employment or applica tio n fo r emp l oyment (including contract for serv i ces ), consumer reports may be requested from HireRight or other
Consumer Report i ng Agencies ( " CRA "). These r eports may include the following types of i nformation : names and dates of previous employers, reason for termination of employment , credit reports work ex perience , acc i dents , academic histo r y , p r ofessional credentials , and drug/alcoho l use. Such reports may contain public record informat i on concerning your drivin g record , workers ' compensation claims , credit, bankrup t cy proceed i ngs , criminal records , etc . from federal , state and other agencies which maintain such r ecor ds ; as well as informat i on from CRA concerning previous dr i ving reco r d requests made by others from such state agencies and state p r ovided driving records . I f f i na l adverse action is taken against you based upon a background report , PAYMASTERS will notify you that the action has been taken and that t he backg r ound report was t he reason for the action .
I authorize PAYMASTERS to contact any organization or in d i v i dual that I have listed on my employment application or resume or mentioned in job interviews and obtain from t hem any relevant information about my j ob qu a l i fications , including my experience , skil l s and abilities . I understand that I am consenting to the release of safety performance information inc l uding crash data fro m the previous five ( 5 ) years and inspect i on history from the previous three ( 3 ) years , as well as any reference- related information about me held or k n own by my fo r mer employers , supervisors , and co-workers . I n addit i on I consent to the release of any info r mat i on about my education , experience , abilities , or wor k -relate d c haracter i s t ics or traits held or known by o t her organiza t ions or individuals , includ i ng schools and educational ins t itutions , professional o r business assoc i ate s , and friends and acqua i ntances that PAYMASTERS might contact in the course of conducting a reference check or b ackg r ound invest i gation of my suitabil i ty f or e mp loyment . You have the right to make a request to CRA , upon proper identification , to request the nature and substance of al l in f ormation in its files on you a t t he t i me of you r request , including the sou r ces of i nformat i on and the recipients of any reports on yo u that CRA previously furnished within the three-yea r per i o d preced i ng your request . PAYMASTERS can be contacted by ma i l at PO Box 1567 Detroit Lakes,
MN 56502 or by phone at 218-844-7560 . Information about Hire R i ght ' s pr i vacy p r actices is available at www .
hirerigh t .
com/pr i vacy policy.asp
x .
I AUTHORIZE , WITHOUT RESERVATION , AN Y PARTY OR AGENCY CONTRACTED BY CRA , TO FURNISH THE ABOVE-MENTIONED
INFORMATION . THIS AUTHORIZATION DOES NOT APPLY T O DRUG AND ALCOHOL INFORMATION OBTAINED UNDER PART 1 .
I hereby consent to your obtaining the above in fo rmation from CRA , and I agree that such i nformation which CRA has or obtains , and my employment history ( not
Drug and Alcohol information without a spec i f ic c onsent from me) with you if I am hired , will be supplied by CRA to other companies which subscribe to CRA . I hereby author i ze procurement of consumer rep o rt ( s ) . If hired or contracted this authorizat i on , for Part 2 reports only , sha l l remain on fi l e and shall serves as ongo i ng author i zation for you to p r ocure consu m e r reports at any time during my employment or contract period . I understand and acknowledge that this re l ease of i nformat i on can involve my qualifications , perfo rm ance , c r edentia l s , o r other character i st i cs or factors af f ecting my suitability for employment w i th
PAYMASTERS. Specifically , I am authorizing the re l ease of an y i nf ormat i on about my performance , e x pe r ience , capabili t y , att i tude , specific events , or other workrelated c haracteristics tha t cu r rently are in the possess io n o f the requested organizat i ons or t he i r managers or representatives .
I n e x change for PAYMASTERS ' s consideration of my em ployment appl i cat i on , I ag r ee not to f i le or pursue any compla i nts , cla i ms ; or legal act i ons of any kind against any organiza t ion or i ndivid u al that provides wor k -r e l a t e d i nformation abou t me to PAYMASTERS or its agents i n accordance w it h the terms and intent of this release . I also agree n o t to f i le or pursue a n y complaints , claims , or le gal actions aga i nst PAYMASTERS or any of i ts employees , representatives , or agents arising ou t of their efforts to obtain w or k -re l ated informat i on about me .
I have read the above Consumer Report D i sclo s ure and Release provided to me by PAYMASTERS and I understand that if I sign this consent form ,
PAYMASTERS and l/ or any entity it retains to obtain such background repo r ts may o b t ain reports of my credit , dr i ving , and/or criminal background history in addition to information regarding my background , references , education , spec i f i c ev en ts , and past employment . I hereby author i ze PAYMASTERS , its employees , agents , and affil i ates to obtain the information authorized above .

I am aware that a consumer report, (motor vehicle record) will be obtained on me in the course of consideration for employment and at times throughout my employment.
I hereby authorize, without reservation, any party, state, or agency contracted by
, to furnish the above mentioned information.
I hereby authorize procurement of consumer report(s), If hired (or contracted) this authorization shall remain on file and serve as ongoing authorization for you to procure consumer reports at any time during my employment (or contract) period.
First Name:
Middle Name:
Last Name:
Address (No PO Box):
City:
State, Zip
Social Security #:
Date of Birth:
/_
/_
Driver License #:
State Driver s License Issue:
/
/_
Signature: Date:

I hereby acknowledge that I have received a copy of the Federal Motor Carrier Safety
Regulations, 49 CFR parts 40 and 382, 383 and 390 397 of the Department of
Transportation.
I agree to familiarize myself with these regulations and to comply with all the provisions of these regulations. I will also follow all company procedures as required by the Motor Carrier.
Name of Driver
Driver s Signature_
Name of Motor Carrier Raveill Trucking, Inc.
Signature of Motor Carrier
Date

DF - 6
(For Newly Hired Drivers)
INSTRUCTION: 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.
Driver Name (Print)
Social Security Number
Drive icense: State
Type of License
1
(yesterday)
DAY
DATE
HOURS
WORKED
Number
2 3 4
Class Endorsement(s)
Issuing State
5 6 7
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
A.M.
P.M. On
Day Month Year
Restriction(s)
TOTAL HOURS
Signature Date
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 nonmotor carrier entity.
(check one)
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 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.
Signature Date
Witness:
Company Representative Date

The format of this sample policy does not have to be followed as written, but your policy shall include all information listed in CFR Part 382.601 (b) (1 11).
For:
Herein referred to as (The Company)
Purpose
It is the policy of (The Company), that its drivers shall be free of substance abuse and alcohol abuse. The use of illegal drugs by drivers is prohibited. Furthermore, drivers shall not use alcohol or engage in prohibited condu as defined herein. The overall goal of this policy is to promote a drug and alcohol-free transportation environment and to reduce accidents, injuries, and fatalities.
Definitions Refer to CFR Part 382 for complete definitions
Commercial Motor Vehicle: A motor vehicle or combination of motor vehicles used in commerce to transport passengers or property if the vehicle
1. has a gross combination weight rate of greater than 26,001 pounds inclusive of a towed unit with a gross vehicle weight rating of more than 10,000 pounds or; has a gross vehicle weight rating of greater than 26,001 pounds, or;
2. is designed to transport 16 or more passengers, including the driver, or;
3. is of any size and used in the transportation of hazardous materials (see 49 U.S.C. 5103(b) and which require the motor vehicle to be placarded (see 49 CFR part 172, subpart F).
Designated Employer Representative (DER): Individual identified by employer as able to receive communications and test results from service agents and who is authorized to take immediate action to remove employees from safety-sensitive duties and to make decisions in the testing and evaluation process.
The individual shall be an employee of the company.
Driver: Any person who operates a commercial motor vehicle. Includes, but is not limited to: full time, regularly employed drivers, casual, intermittent or occasional drivers, leased drivers and independent owner-operator contractors.
Safety-Sensitive Function: all time from the time a driver begins to work or is required to be ready to work until the time he/she is relieved from work and all responsibility for performing work.
Prohibitions:
Alcohol:
1. Drivers shall not report to/or remain on duty while having an alcohol concentration level of 0.04 or greater.
2. Drivers shall not use alcohol while performing safety-sensitive functions.
3. Drivers shall not use alcohol 4 hours prior to performing safety-sensitive functions.
4. Drivers shall not use alcohol for 8 hours following an accident or until he/she undergoes a postaccident alcohol test, whichever occurs first.

Controlled Substances:
1. Drivers shall not report or remain on duty when the driver uses any controlled substance, except in accordance with 382.107 if a licensed medical practitioner has advised the driver that the substances will not effect his/her ability to safely operate a CMV.
2. Drivers shall not report, remain on duty or perform safety sensitive functions if he/she tests positive, has adulterated or substituted their specimen for controlled substances.
Types of Tests
Department of Transportation (DOT) requires six circumstances for drug and alcohol tests. They are (1) preemployment, (2) post-accident, (3) random, (4) reasonable suspicion, (5) return-to-duty, (6) follow-up.
Refusal to Test 49 CFR Part 40, (40.261)
No driver shall refuse to submit to either alcohol or controlled substances tests. Refusals to test are violations and shall require the same consequences as positive results. The following are examples of refusals to test:
1)
2)
3)
4)
5)
6)
Failure to appear within a reasonable amount of time from scheduled appointment
(except in a pre-employment scenario)
Failure to remain at collection site
Failure to provide adequate amount of urine, breath or saliva and there is no valid medical explanation
Failure to undergo a medical examination when required to do so
Failure to sign Step 2 of the Alcohol Testing Form (ATF)
Failure to cooperate with any part of the testing process
Consequences of Policy Violation
Any driver who becomes unqualified or engages in prohibited conduct as set forth herein may be subject to termination of employment.
Pre-Employment Testing
All applicants for driving positions shall submit to urine drug tests. An applicant may not be required to submit to a urine drug test if:
1)
2)
(the Company) can verify that the driver has participated in a valid drug testing program within the preceding 30 days. while participating in that program, the driver was either tested within the past 6 months or participated in a random selection program for the previous 12 months. (The Company) shall also verify that no prior employer of the driver has records indicating a violation of any DOT rule pertaining to controlled substance use within the previous 6 months.
Random Testing
(The Company) conducts random drug and alcohol testing. (The Company) or its agents shall submit all drivers to a random selection system. The random selection system provides an equal chance for each driver to be selected each time random selection occurs. Random selections shall be reasonably spread throughout the year. (The Company) shall select, at a minimum, 50 percent of driver positions in each calendar year. (The Company) shall select, at a minimum,
10 percent of the average number of driver positions for the random alcohol testing. Random selection, by its very nature, may result in driver s being selected in successive selection or more than once a calendar year.
If a driver is selected at random, for either drug or alcohol testing, a (The Company) official shall notify the driver. Once notified, every action the driver takes shall lead to a collection. If the driver engages in conduct that does not lead to a collection as soon as possible after notification, such conduct may be considered refusal to a test.
Post-Accident Testing
When an accident involves a human fatality, surviving drivers shall submit to post-accident drug and alcohol testing.
When a driver is involved in an accident that requires immediate medical treatment away from the scene or disabling damage to any motor vehicle requiring tow away AND is issued a citation, the driver shall submit to a drug and alcohol test.

The DOT requires that any time a post-accident drug or alcohol test is required, that it be performed as soon as possible following the accident. If no alcohol collection can be made within 8 hours, attempts to collect an alcohol sample shall cease. If no urine collection can be obtained for purposes of post-accident drug testing within 32 hours, attempts to make such collection shall cease.
Reasonable Suspicion Testing
Reasonable suspicion for requiring a driver to submit to drug and/or alcohol testing shall be deemed to exist when a driver manifests physical or behavioral symptoms or reactions commonly attributed to the use of controlled substances or alcohol. Such driver conduct shall be witnessed by at least one supervisor trained in compliance with CFR 382.603.
Prohibited Conduct
The following shall be considered prohibited condu for purposes of the policy: No driver shall report for duty or remain on duty while having breath alcohol concentration of .04 or greater.
No driver shall be on duty or operate a commercial motor vehicle while the driver possesses alcohol unless the alcohol is manifested and transported as part of a shipment.
No driver shall use alcohol while performing safety-sensitive functions, including driving, loading, unloading, maintaining or repairing a commercial motor vehicle, and seeking assistance or remaining in attendance with a disabled commercial motor vehicle.
No driver required to take a post-accident alcohol test shall use alcohol for eight hours following the accident or until he/she undergoes a post-accident alcohol test, which ever occurs first.
No driver shall refuse to submit to a post-accident, random, a reasonable suspicion, return-to-duty, or a follow-up breath alcohol or urine drug test.
No driver shall report for duty or remain on duty when the driver uses any controlled substance, except when use is pursuant to the instruction of a physician who has advised the driver that the substance does not adversely affect the driver s ability to operate a motor vehicle.
If (The Company) has actual knowledge or has reason to believe that a driver has engaged in prohibited conduct; (The
Company) may require the driver to submit to drug and/or alcohol testing.
If a driver engages in prohibited conduct, the driver is not qualified to drive a commercial motor vehicle and shall be immediately removed from service. (The Company) may in its discretion, at the request of the driver, keep the driver s position open while such driver attempts to become re-qualified. (The Company) may also take action against the employee up to and including termination.
Substance Abuse Evaluation
(The Company) shall provide a list of names, addresses and telephone numbers of qualified substance abuse professionals to employees (including new applicants) who violated DOT drug and alcohol regulations. If the driver desires to become re- qualified, the driver shall be evaluated by a Substance Abuse Professional (SAP) and submit to the SAPs recommendations which may include education and treatment, in order to become re-qualified. The driver shall submit to and successfully complete a return-to-duty drug and/or alcohol test. Such driver is also subject to follow-up testing. Follow-up testing is separate from and in addition to (The Company s) reasonable suspicion, postaccident, and random testing procedures. Follow-up testing shall be on a random basis and be in accordance with the instruction of the SAP. Follow-up testing may continue for a period of up to 60 months following the driver s return to duty. No fewer than 6 follow-up tests shall be performed in the first 12 months. The costs of the SAP evaluation, education and prescribed treatment shall be discussed with the driver and shall be a company decision based on benefits and union agreements. (The Company) does not guarantee or promise a position to the driver should he/she regain qualified status.
Authorization for Previous Test Records (49 CFR 40.25)
Within 30 days of performing a safety sensitive function, federal regulations require that (The Company) obtain certain drug and alcohol testing records from the driver s previous employers. The records of the past two years regarding drug and alcohol testing records as required to be provided to employers under federal regulation.

Urine Specimen for Controlled Substances
Drug testing shall be performed on urine samples and shall be tested for the presence of drugs and/or metabolites of the following controlled substances: (1) marijuana, (2) cocaine, (3) opiates, (4) phencyclidine (PCP), and (5) amphetamine/methamphetamine. Collectors who have received formal training shall perform collections of urine specimens. Urine specimens shall be tested at a Substance Abuse and Mental Health Services Association
(SAMHSA) certified laboratory. Specimens shall undergo a screening test, and if necessary, a confirmation test.
Test results shall be reported by the laboratory to a Medical Review Officer (MRO) designated by (The Company).
Pursuant to DOT regulations, individual test results for driver/applicants and drivers shall be released to (The
Company) and shall be kept strictly confidential unless consent for the release of the test results has been obtained.
Any individual who has submitted to drug testing in compliance with this policy is entitled to receive the results of such testing upon timely written request.
An individual with verified positive test results shall be offered, by the MRO, the opportunity to have a portion of the original sample sent to a different SAMHSA-certified laboratory. The sample shall be tested for the presence of the controlled substance(s) found in the initial screening and confirmation testing procedures. The individual shall decide to have the split specimen tested within 72 hours of the initial notification of the positive result. (The Company) shall ensure that the test takes place even if the individual does not have the funds to pay for the test. (The Company) may elect to collect payment from the individual for the costs of the additional testing procedure.
Alcohol Tests
(The Company) shall perform initial alcohol tests using saliva or breath testing methods approved by the Department of
Transportation. The driver shall follow all instructions given by the alcohol testing technician. In the event a driver tests positive on the initial test, he/she shall submit to a confirmation test performed on an approved evidential breath testing analyzer. If the confirmation result is 0.02 to 0.039, the driver shall be removed from duty for 24 hours or until his/her next scheduled on-duty time frame expires. Drivers with tests indicating an alcohol concentration 0.04 or higher are considered to have violated DOT regulations, shall be removed from safety-sensitive duties and shall be referred to a substance abuse professional (SAP). Random, post-accident and alcohol tests shall be performed just prior to, during, or just after duty.
Return-to-duty tests shall be performed after the SAP has determined the employee has successfully complied with prescribed education and/or treatment.
Training
(The Company) shall ensure supervisors designated to determine whether reasonable suspicion exists to require a driver to undergo testing, receive at least 60 minutes of training on alcohol misuse and at least 60 minutes of training on controlled substances use. The training shall cover the physical, behavioral, speech, and performance indicators of alcohol misuse and use of controlled substances.
(The Company) shall provide educational material that explains the requirements of 382.601, consequences of violating the regulations, and the employe s policies and procedures with respect to meeting these requirements.
(The Company) shall ensure each driver is required to sign a statement certifying that he or she has received a copy of these materials described in CFR 382.601.
The policy is not intended nor should it be construed as a contract between (The Company) and the employee. This policy may be changed at any time at the sole discretion of (The Company). If you have any questions concerning the information please contact.
Name and phone number of person responsible for
(The Company)
Alcohol & Controlled Substance Testing
Program

(Name and signature of driver)
(Company representative)
Name of Company: Raveill Trucking, Inc.
(date)
(date)