Transcription
1311 E CR 119 Midland, Tx 79706 432.250.0554 DOT@pegasoenergyservices.comDear Potential Employee:Thank you for considering Pegaso Energy Services, LLC. as a place of employment.Pegaso Energy Services, LLC, is one of the best in the industry in terms of safety. Our company receives nationalrecognition from various insurance providers, customers, and trade organizations for numerous safety andpersonnel safety achievements.The safety of our employees and the public is our utmost priority. Our safety record and performance are basedon our foundations: screening, safety training, supervision and response speed. To maintain such commitment,prior to commencing a safety sensitive function, the Company requests certain items needed to establish your DOTDriver Qualification file.Please complete all forms in a legible printed format and sign where required. If a section does not apply, write inN/A. On the additional pages, only complete areas indicated.IMPORTANT! You must fully complete the ten-year work history (including both driving and non-driving positionsas well as paid and unpaid positions). If there is a gap in employment, please be sure to document the gap toexplain why you were unemployed or what you were doing during that time.If more space is needed, please use a separate sheet of paper. Incomplete or intentionally undisclosedinformation on an application is grounds for disqualification.Additional pages include a Request for Driver’s Safety Performance History/Information from DOT RegulatedPrevious Employer(s), Job Description for Company Representative, Controlled Substance and Alcohol TestingInformation, Acknowledgement/Consent Form, and Driver’s Rights Pertaining to Release of Driver InformationUnder Regulation 391.23.We appreciate your interest and look forward to receiving your application.Thank you,Pegaso Energy Services1 Page
DRIVER NAMEJOB TITLEDATE OF 9.20.21.1.2.3.4.5.6.DRIVER QUALIFICATION FILE CHECKLISTDOT Employment ApplicationFMCSA Signed ReleaseMVRCDLIS (if applicable)FMCSA Employment Background (3-year minimum history search)Driver’s Statement of On-Duty HoursCompleted Record of Road Test or EquivalentCertification of Violations/ Annual Review of Driving RecordCopy of driver’s license (front and back)Pre-employment drug test resultsPre-employment alcohol test results (if conducted, not required)Affidavit to Authorize Release of CDL Holder Reported Positive Controlled Substance Test Results(TX, AR only)FMCSA Clearinghouse Consent FormFMCSA Clearinghouse Query ResultsCopy of Medical Examiner’s cardMedical Examiner National Registry VerificationMVR- to Confirm Med Card Reported to State or Texas Medical Card Registry (if Tx driver)Copy of SPE or State or Federal issued waiver (if marked on Medical Examiner’s card)Certification of Compliance with CDL Requirements (not required)Driver’s Rights Pertaining to Release of Driver Information 391.23Brake Inspector (if will be working on brakes)TRAININGFMCSA Pocketbook ReceiptGeneral AwarenessDrug and Alcohol AwarenessHazmat: General Awareness (if applicable)Hazmat: Security (if applicable)Entry Level Training (if less than 1-year experience)2 Page
EMPLOYMENT APPLICATION FOR DOT REGULATED POSITIONSLeave no question blank. Answer each inquiry or mark with “N/A” or “none” as appropriate.(Name)(SSN)(Phone)(Date of birth)(Email)Address(es) for past three years(No. & Street)(CURRENT ADDRESS)(City)(State)(Zip)(No. & Street)(City)(State)(Zip)(No. & Street)(City)(State)(Zip)Provide your unexpired motor vehicle operator’s license or permit information and endorsement(s)State:License No.:Expiration Date:License Class:Endorsements:List State and DL# for any other driver licenses held in the previous three (3) years.1.State:License No.:Expiration Date:2.State:License No.:Expiration Date:When were you issued your first CDL?(Answer N/A if non-CDL driver to this & question below)What was your first year of employment that required you to use a CDL license?Motor Vehicle Violations (other than parking) resulting in conviction, bond or collateral forfeiture (3years prior to application date)1.2.3.State in detail all facts and circumstances of any denial, revocation or suspension of any license,permit or privilege to operate a motor vehicle. Must initial below if “none or n/a” answered above.(Initial Here)No denial, revocation or suspension has occurred.3 Page
Vehicle accident history (3 years prior to application date)1.2.3.DateNature of accidentFatalities? (Y/N)Injuries? (Y/N)DateNature of accidentFatalities? (Y/N)Injuries? (Y/N)DateNature of accidentFatalities? (Y/N)Injuries? (Y/N)Operating experience with motor vehicles1.2.3.4.5.Type of vehicle/equipment operatedDates (from-To)Approximate Total MilesType of vehicle/equipment operatedDates (from-To)Approximate Total MilesType of vehicle/equipment operatedDates (from-To)Approximate Total MilesType of vehicle/equipment operatedDates (from-To)Approximate Total MilesType of vehicle/equipment operatedDates (from-To)Approximate Total MilesPrevious 10 years employment history; use additional page if necessary. If self employed, listregistered business name.1.EmployerAddressPhoneJob TitleFaxEmailDates (from -to)Was this job regulated? YesNoWas job designated as a safety sensitive function subject to USDOT Alcohol & controlled substances testing? YesNoAccount for period between jobs (include dates and reason)2.EmployerJob TitleAddressPhoneFaxEmailDates (from -to)Was this job regulated? YesNoWas job designated as a safety sensitive function subject to USDOT Alcohol & controlled substances testing? YesNoAccount for period between jobs (include dates and reason)4 Page
3.EmployerAddressPhoneJob TitleFaxEmailDates (from -to)Was this job regulated? YesNoWas job designated as a safety sensitive function subject to USDOT Alcohol & controlled substances testing? YesNoAccount for period between jobs (include dates and reason)4.EmployerAddressPhoneJob TitleFaxEmailDates (from -to)Was this job regulated? YesNoWas job designated as a safety sensitive function subject to USDOT Alcohol & controlled substances testing? YesNoAccount for period between jobs (include dates and reason)5.EmployerAddressPhoneJob TitleFaxEmailDates (from -to)Was this job regulated? YesNoWas job designated as a safety sensitive function subject to USDOT Alcohol & controlled substances testing? YesNoAccount for period between jobs (include dates and reason)6.EmployerAddressPhoneJob TitleFaxEmailDates (from -to)Was this job regulated? YesNoWas job designated as a safety sensitive function subject to USDOT Alcohol & controlled substances testing? YesNoAccount for period between jobs (include dates and reason)7.EmployerJob TitleAddressPhoneFaxEmailDates (from -to)Was this job regulated? YesNoWas job designated as a safety sensitive function subject to USDOT Alcohol & controlled substances testing? YesNoAccount for period between jobs (include dates and reason)5 Page
Employee Physical Qualification: Pursuant to 49 CFR Sections 391.41 please respond to the followingquestions:1) Do you have a condition that requires a medical waiver or a Skills Performance Evaluation Certificate?Check one:YesNo2) If yes checked in question 1, I have provided a valid:Check the box (es) that apply:State Issued WaiverFederal Issued WaiverSPE certificateEmployee Drug and Alcohol Statement: Pursuant to 49 CFR Sections 391.23 and 40.25 please respond to thefollowing questions:1) Have you tested positive, or refused to test, on any drug or alcohol test administered under DOT agencydrug and alcohol testing rules during the past three years?Check oneYesNo2) Have you tested positive, or refused to test, on any pre-employment drug or alcohol test administered byan employer to which you applied for, but did not obtain, safety-sensitive transportation work covered bythe DOT agency drug and alcohol testing rules during the past two years?Check oneYesNo3) If yes answered to questions 3 and/or 4 above, can you obtain/provide proof that you have:Check all that apply:Been evaluated and released to perform DOT Safety Sensitive Functions by a SAPSuccessfully completed the DOT return to duty testing requirementsSuccessfully completed the DOT follow-up testing requirementsThis certifies that this application was completed by me, and that all entries on it and information in itare true and complete to the best of my knowledge. I also understand that the information providedin this application may be used, and my prior employers may be contacted as required by the FederalMotor Carrier Safety Regulations. Pursuant to paragraphs 391.23 (d) and (e), I am aware that I haverights to request in writing access to review or correct any erroneous investigative informationprovided from a previous employer.(Date)(Applicant’s signature)6 Page
THIS SECTION TO BE COMPLETED BY APPLICANTIn compliance with the U.S. Department of Transportation (DOT) regulations (49 CFR 391.23) as a condition of employment in a DOT safetysensitive position, applicants must provide the names and addresses of previous employers for whom they perform worked in a safety-sensitivefunction that required alcohol and controlled testing specified by 49 CFR part 40 and 382. The applicant must provide a signed consent forrelease of the information listed below to be placed in a DOT CDL position.I,SSNin accordance with 49 CFR Part 40, 382 and 391authorize and request the company identified below provide the DOT drug and alcohol testing, along with my Safety Performance History toPegaso Energy Services, LLC.Company NameApplicants SignatureAddressTelephone NumberDates of EmploymentDate7 Page
SECTION A & B TO BE COMPLETED BY PREVIOUS EMPLOYER7. Did the applicant have any alcohol tests with a result of 0.04 or higher alcohol concentration?8.Did the applicant have any verified positive drug tests?9. Did the applicant refuse to be tested (include verified adulterated or substituted drug test results?)10. Do you know if the applicant failed to undertake or complete a rehabilitation program prescribed by aSubstance abuse professional (SAP) pursuant to 49 CFR Part 382.605 or 49 CFR Part 40 Subpart O?(If this information is unknown by the previous employer (e.g., an employer that terminated an employeewho tested positive on a drug test), the prospective motor carrier must obtain documentation of theapplicant’s successful completion of the SAP’s referral directly from the applicant.The United States Department of Transportation (DOT) regulations (49 CFR Part 40, 382 and 391) require companies that are regulatedby the DOT to answer specific questions regarding individuals who were employed by them in a DOT regulated safety-sensitive positionwithin the three previous years. Please answer the following questions, If there is information to report for that driver, previous motorcarrier employers are nonetheless required to send a response confirming the non-existence of any such data, including the driveridentification information and dates of employment.Your Company Name & Address:Dates of Employment: Start:End:Position Held:SECTION A & B TO BE COMPLETED BY PREVIOUS EMPLOYERSECTION A & B TO BE COMPLETED BY PREVIOUS EMPLOYERThis employee was not subject to DOT drug and alcohol testing. (IF THISEMPLOYEE WAS NOT SUBJECT TO DOT DRUG AND ALCOHOL TESTING, BUT DROVE A COMMERCIAL MOTORVEHICLE (UNDER 26,000) PLEASE COMPLETE SECTION B.)If subject to testing, please respond to the following questions by checking the appropriate boxes.YesNoDrug Testing History Questions1. Did the applicant have an alcohol test with a result of 0.04 or higher alcohol concentration?2.Did the applicant have verified positive drug tests?3. Did the applicant refuse to be tested (including verified adulterated or substituted drug test results)?4.Did the applicant violate any DOT agency drug and alcohol testing regulations or violate the alcohol andcontrolled substances prohibitions under 49 CFR Part 382 Subpart B, or 49 CFR Part 40?5.Did a previous employer report a drug and alcohol rule violation to you? If you answered yes, you mustprovide the previous employer’s report.6. For an applicant who had successfully completed a SAP’s rehabilitation referral, and remained in the employof the previous referring employer, had the applicant had the following test violations subsequent to thecompletion of a 49 CFR Part 382.605 or 49 CFR Part 40, Subpart O referral?If the applicant violated a drug and alcohol regulation, provide documentation of the successful completion of DOTreturn-to-duty requirements and information on the substance abuse professional (including follow up tests).Please check the appropriate box below:Not ApplicableDid not complete or refused rehabilitationSee Attached8 Page
SECTION B: SAFETY PERFORMANCE HISTORYThis employee did not drive a commercial motor vehicle subject to FMCSR.If the applicant drove a commercial motor vehicle for your Company, what type of commercial motor vehicle didthe applicant drive? Straight Truck (10,001 lbs. or more) Tractor-Semi Trailer (10,000 lbs. or less) Tractor-Semi Trailer (10,001lbs. or more) Straight Truck (10,000 lbs. or less) Bus Passenger Car Other (Specify Type):While employed by your company, was the applicant involved in any accidents (as defined in § 390.5) in thepast three years? No Yes- If yes, please provide the following information:Date of AccidentCity or town and StateDriver NameNumber of injuriesNumber of fatalitiesNumber where one or more vehicles incurred disablingdamage and had to be removed from the scene by tow truckor other motor vehicleWere hazardous materials released other than fuel spilledfrom the fuel tanks of motor vehicles involved in the accidentCompleted by (Pleaseprint):Title:Date:Phone Number:E-mail:PLEASE COMPLETE AND RETURN VIA MAIL OR E-MAIL TO:Pegaso Energy Services1311 ECR 119 Midland, Tx 79706 DOT@pegasoenergyservices.com9 Page
General Consent for Limited Queries of the Federal Motor Carrier Safety Administration (FMCSA) Drugand Alcohol ClearinghouseI,, hereby provide consent to Pegaso Energy Services,LLC. to conduct an unlimited number of limited queries of the FMCSA Commercial Driver’s License Drugand Alcohol Clearinghouse (Clearinghouse) to determine whether drug or alcohol violation informationabout me exists in the Clearinghouse for the duration of my employment.I understand that if the limited query conducted by Pegaso Energy Services, LLC indicates thatdrug or alcohol violation information about me exists in the Clearinghouse, FMCSA will not disclose thatinformation to Pegaso Energy Services, LLC. without first obtaining additional specific consent from me.I further understand that if I refuse to provide consent for Pegaso Energy Services, LLC. toconduct a limited query of the Clearinghouse, Pegaso Energy Services, LLC. must prohibit me fromperforming all safety- sensitive functions, including driving a commercial motor vehicle, as required byFMCSA’s drug and alcohol program regulations.Driver’s name:Date:Driver’s signature:10 P a g e
DRIVER STATEMENT OF ON-DUTY HOURS FOR NEWLY HIRED DRIVERSRule 395.8(j)(2) Federal Motor Carrier Safety Regulations: Motor carriers when using a driver for the first time shall obtain fromthe driver a signed statement giving the total time on-duty during the immediate preceding 7 days and time at which suchdriver was last relieved from duty prior to beginning work for such carrier.Note: Hours for any compensated work during the preceding 7 days, including work for a non-motor carrier entity, must be recorded on thisform.Driver name (Print)Social Security NumberDriver’s License(State)DAY1 riction(s))7DATEHOURSWORKEDTOTALHOURSI hereby certify that the information given above is correct to the best of my knowledge and belief, and that I was last relievedfrom work at: A.M. P.M. onDriver’s SignatureDayMonthYearDate11 P a g e
DRIVER CERTIFICATION FOR OTHER COMPENSATED WORKINSTRUCTIONS: When employed by a motor carrier, a driver must report to the carrier all on-duty time including time workingfor other employers. The definition of on-duty time found in Section 395.2 paragraphs (8) and (9) of the Federal Motor CarrierSafety regulations includes time performing any other work in the capacity of, or in the employ of service of, a common,contract or private motor carrier, also performing any compensated work for any non-motor carrier entity.Select OneAre you currently working for another employer? Yes NoAt this time, do you intend to work for another employer while still employed by this company? Yes NoI hereby certify that the information given above is true and I understand that once I become employed with this company, if Ibegin working for any additional employer(s) for compensation that I must inform this company immediately of suchemployment activity.Driver’s SignatureDateWitnessDate(Company Representative)12 P a g e
DRIVER’S ROAD TEST EXAMINATIONDriver’s Name:Phone Number:Driver’s Address:City:State:Zip Code:The road test shall be given by the motor carrier or a person designated by the motor carrier. However, a driver who is a motorcarrier must be given the test by another person. The test shall be given by a person who is competent to evaluate and determine whether theperson who takes the test has demonstrated that he or she is capable of operating the vehicle and associated equipment that the motor carrierintends to assign.Rating of PerformanceTask (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 unitsPlacing the commercial motor vehicle in operationUse of the commercial motor vehicle’s controls and emergency equipmentOperating the commercial motor vehicle in traffic and while passing other vehiclesTurning the commercial motor vehicleBraking, and slowing the commercial motor vehicle by means other than brakingBacking and parking the commercial motor vehicleOther, please explain:Type of equipment used in giving the road test:Date:Examiner’s Signature:Examiner’s Title:Examiner’s Printed Name:If the road test is successfully completed, the person who gave it shall complete a certificate of driver’s road test.Examiner’s Remarks:13 P a g e
Instructions: If a road test is successfully completed (see previous form), the person who gave it shall complete acertificate of driver’s road test. The original or a copy must be retained in the employing motor carrier’s driverqualification 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. 391.31Driver's name:Social Security No.:Operator's or Chauffeur's License No.:State:Type of power unit:Type of trailer(s):If passenger carrier, type of bus:This is to certify that the above-named driver was given a road test under my supervision on, 20, consisting of approximatelymiles of driving.It is my considered opinion that this driver possesses sufficient driving skills to operate safely the type ofcommercial motor vehicle listed above.(Signature of examiner)(Title)(Organization and address of examiner)Note: This form is provided as a suggested format for certifying a driver’s road test. A motor carrier may use anyformat for certifying road tests which complies with 391.31.14 P a g e
MOTOR VEHICLES DRIVER’S CERTIFICATION OF VIOLATIONS ANNUALREVIEW OF DRIVING RECORDMOTOR CARRIER INSTRUCTIONS: Each motor carrier, shall at least once every 12 months, require each driver it employs to prepare and furnishit with a list of all violations of motor vehicle traffic laws and ordinances (other than violations involving only parking) of which the drive hasbeen convicted, or on account of which he/she has forfeited bond or collateral during the preceding 12 months (Section
1311 E CR 119 Midland, Tx 79706 432.250.0554 DOT@pegasoenergyservices.com . Dear Potential Employee: Thank you for considering Pegaso Energy Services, LLC. as a place of employment. Pegaso Energy Services, LLC, is one of the best in the i
