EACH ADDRESS FOR THE LAST THREE YEARS (ATTACH SHEET IF MORE SPACE IS NEEDED);
EXPERIENCE AND QUALIFICATIONS (ATTACH SHEET IF MORE SPACE IS NEEDED);
| DRIVER LICENSES | ||||
|---|---|---|---|---|
| STATE | LICENSE NUMBER | CLASS | ENDORSEMENTS | EXPIRATION DATE |
| DF | DF001153189 | B INT | 1/10/2027 | |
| DRIVING | ||||
|---|---|---|---|---|
| CLASS OF EQUIPMENT | TYPE OF EQUIPMENT (VAN, TANK, FLAT, ETC) | DATE FROM TO |
APPROXIMATE NUMBER OF MILES (TOTAL) | |
| Straight Truck | 11/14/2018 | 12/30/2024 | 325000 | |
| Tractor-Semi Trailer | ||||
| Tractor-Multiple Trailer | ||||
| Other | ||||
| ACCIDENTS | ||||
|---|---|---|---|---|
| DATES (LAST THREE YEARS) (LIST MOST RECENT FIRST) |
NATURE OF ACCIDENT (HEAD-ON, REAR END, UPSET, ETC) | FATALITIES | INJURIES | |
| TRAFFIC CONVICTIONS AND FORFETURES | ||||
|---|---|---|---|---|
| LOCATION | DATE | CHARGE | PENALTY | |
Note: This form is provided as a suggested format for a commercial motor vehicle driver's application for employment. A motor carrier may use any format for an application for employment which complies with 201.21.
ADVERSE LICENSING ACTIONS:
- A. Have you ever been denied a license, permit, or privilege to operate a motor vehicle? No
- B. Has any license, permit, or privilege to operate a motor vehicle been suspended or revoked? No
Explain below(or attach separate sheet if more space is needed);
EMPLOYMENT RECORD (ATTACH SHEET IF MORE SPACE IS NEEDED):
Note: Requires that you list your employment history' for at least the last 3 years and your Commercial Driving Experience for the Past 10 years:
APPLICANT MUST COMPLETE OR REVIEW THE ABOVE
APPLICANT'S ORIGINAL SIGNATURE MUST APPEAR BELOW
This certifies that this application was completed by me, and that all entries on ft and information in it are true and complete to the best of my knowledge.
EMPLOYMENT RECORD (ADDITIONAL JOBS):
REQUEST FOR EMPLOYMENT INFORMATION FROM PREVIOUS EMPLOYER
PREVIOUS EMPLOYER:
ADDRESS:
Section 1 Prospective employer:
Section 2 Prospective employee:
Section 3 Previous employer:
| Excellent | Good | Fair | Poor | Very poor | |
|---|---|---|---|---|---|
| Quality of work | |||||
| Cooperation with others | |||||
| Safety habits | |||||
| Personal habits | |||||
| Driving skill | |||||
| Attitude |
PART 3:
TO BE COMPLETED BY PREVIOUS EMPLOYER
DRUG AND ALCOHOL HISTORY
If driver was not subject to Department of Transportation testing requirements while employed by this employer, please check here , fill in the dates of employment from 10/21/2024 to 12/30/2024 complete bottom of Part 3. sign, and return.
Driver was subject to Department of Transportation testing requirements from 10/21/2024 to 12/30/2024
-
Has this person had an alcohol test with the result of 0.04 or higher alcohol concentration?
YES NO - Has this person tested positive or adulterated or substituted a test specimen for controlled substances?
YES NO -
Has this person refused to submit to a post-accident, random, reasonable suspicion, or follow-up alcohol orcontrolled substance test?
YES NO -
Has this person committed other violations of Subpart B of Part 382, or Part 40?
YES NO -
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 -
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?
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.
PART 4a:
TO BE COMPLETED BY PROSPECTIVE EMPLOYER
PART 4b:
TO BE COMPLETED BY PROSPECTIVE EMPLOYER
Complete below when information is obtained.
INSTRUCTIONS TO COMPLETE THE SAFETY PERFORMANCE HISTORY RECORDS REQUEST
PAGE 1 PART 1:Prospective Employee
- Complete the information required in this section
- Sign and date
- Submit to the Prospective Employer
PAGE 2 PART 4a:Prospective Employee
- Complete the information
- Send to Previous Employer
PAGE 1 PART 2:Previous Employer
- Complete the information required in this section
- Sign and date
- Turn form over to complete SIDE 2 SECTION 3
PAGE 2 PART 3:Previous Employer
- Complete the information required in this section
- Sign and date
- Return to Prospective Employer
PAGE 2 PART 4b:Prospective Employer
- Record receipt of the information
- Retain the form
REQUEST FOR DRIVING RECORD
The above named individual has made application with us for employment as a driver. Applicant has indicated that the above
numbered operator's license or permit has been issued by your state to applicant, and that it is in good standing.
In accordance with 49 C.F.R. 391.23(a)(1) of the Federal Motor Carrier Safety Regulations, we are required to make an inquiry
into the applicant's driving record during the preceding 3 years of every state in which the applicant has held a motor
vehicle operator's license or permit during those 3 years.
Therefore, please certify to us what the individual's driving record is for the preceding 3 years, or certify that
no such record exists if that be the case.
In the event this letter does not satisfy your requirements for making such inquiries, please send us instructions
and forms of yours as are necessary for us to complete our inquiry into the driving record of this applicant.
Respectfully yours,
Note: This form is provided as a suggested format for requesting a driving record from a jurisdiction other than Texas. No format is prescribed, and each jurisdiction may have its own form.
DRIVER'S ROAD TEST EXAMINATION
The road test shall be given by the motor carrier or a person designated by the motor carrier. However, a driver who is a
motor carrier must be given the test by another person. The test shall be given by a person who is competent to evaluate
and determine whether the person who takes the test has demonstrated that he or she is capable of operating the vehicle
and associated equipment that the motor carrier intends to assign.
Task (as required by 49 C.F.R. 391.31)
The pre-trip inspection (as required by 49 C.F.R. 392.7)
Coupling and uncoupling of combination units, if the equipment he/she may drive includes combination units
Placing the commercial motor vehicle in operation
Use of the commercial motor vehicle's controls and emergency equipment
Operating the commercial motor vehicle in traffic and while passing other vehicles
Turning the commercial motor vehicle
Braking, and slowing the commercial motor vehicle by means other than braking
Backing and parking the commercial motor vehicle
Other, please explain:
If the road test is successfully completed, the person who gave it shall complete a certificate of driver's road test.
Note: This form is provided as a suggested format for recording a driver's road test. A motor carrier may use any format for documenting road tests which complies with 391.31.
Instructions: If a road test is successfully completed (see previous form), the person who gave it shall com- plete a certificate of driver's road test. The original or a copy must be retained in the employing motor car- rier's driver qualification file for the person examined. A copy should be given to the person who was examined.
CERTIFICATION OF ROAD TEST UNDER 49 C.F.R. 391.31
1/2/2025 , consisting of approximately 10 miles of driving.
It is my considered opinion that this driver possesses sufficient driving skills to operate safely the type of commercial motor vehicle listed above.
Note: This form is provided as a suggested format for certifying a driver's road test. A motor carrier may use any format for certifying road tests which complies with 391.31.
DRIVER PROFICIENCY (CAC 13, 1229) and
AUTHORIZED VEHICLES (CAC 12, 1234 (b)
That he/she can safely operate the below named vehicles/equipment as was trained for the following:
Straight truck
Informed on who to report safety concerns to
Tractor & trailer combination
Trained on how to secure a load. Tiedown procedure
Tank vehicle
Trained on spotting an improperly loaded vehicle
Vehicles 10,000 pounds to 26,000 pounds GVWR
Trained on safe use of mirrors & blind spois
Vehicles 26,001 pounds and more GVWR
Standard shift transmission
Properly hook up a trailer
Automatic transmission only
Safely operate a dump vehicle
Air brakes endorsement
Trained to perform a walk around inspection
Hazardous materials endorsement
Other
A LONG FORM MEDICAL EXAMINATION REPORTS IS REQUIRED
COPY OF MEDICAL EXAMINER'S CERTIFICATE HERE
Internal Instructions:
Dispatch Dept:
All new hires must be directed to the Equipment Manager, with this form, for completion of the Driver Proficiency Process
Equipment Dept:
Process completed copy of this form to Payroll for recordkeeping
General Consent for Limited Queries of
the Federal Motor Carrier Safety Administration (FMCSA)
Drug and Alcohol Clearinghouse
I CHRISTIAN OTHONIEL LOPEZ SUAREZ hereby provide consent to LOLETIS TRANSPORT LLC to conduct a limited query of the FMCSA Commercial Driver’s License Drug and Alcohol Clearinghouse DF001153189 to determine whether drug or alcohol violation information about me exists in the Clearinghouse.
I understand that if the limited query conducted by LOLETIS TRANSPORT LLC indicates that drug or alcohol violation information about me exists in the Clearinghouse, FMCSA will not disclose that information to (COMPANY) without first obtaining additional specific consent from me.
I further understand that if I refuse to provide consent for LOLETIS TRANSPORT LLC to conduct a limited query of the Clearinghouse, LOLETIS TRANSPORT LLC must prohibit me from performing safety-sensitive functions, including driving a commercial motor vehicle, as required by FMCSA’s drug and alcohol program regulations.
Certificate of receipt of LOLETIS TRANSPORT LLC drug and alcohol policy for DOT regulated drivers.
I certify that I am in receipt of, have read, and do understand LOLETIS TRANSPORT LLC policies, procedures, and educational materials regarding substance-abuse prevention and substance-abuse testing, as required by the Federal Motor Carrier Safety Administration.
Specifically, I certify have received detailed information setting forth: (1) the identify of the person designated to answer questions about the Company’s Drug and Alcohol Policy for DOT-Regulated Drivers (“Policy”); (2) who is covered by the regulations; (3) what is meant by “safety-sensitive functions” so that I understand what period of the workday I am required to be in compliance with the regulations; (4) what is prohibited by the regulations and by the Company’s Policy; (5) the circumstances under which I will be tested; (6) the procedures for testing; (7) the requirement that I submit to testing as required by the regulations; (8) an explanation of what constitutes a refusal to-test, and the consequences for refusing to submit to testing; (9) the consequences under the regulations and the consequences as a matter of Company policy if I violate the regulations and/or test positive; (10) the consequences if I test positive for alcohol at the level of .02 or greater; and (11) information concerning the effects of alcohol and drug abuse on my health, work, and personal life, and signs and symptoms of alcohol or drug problems. I understand that if I am concerned about my use of alcohol or controlled substances, or the use of alcohol or controlled substances by a co-worker, I can and should seek assistance from the Company’s or from an appropriate assistance program in my community.
I understand that I may have a copy of this certificate of receipt if I so request.