Including; The Pre-Trip, during the work shift and post trip
Also enter driver and owner operator details that we need these documents from them .
Certain precautions must be taken regarding the usage of any medication prescribed
by your physician (382.213). It is in your interest, as well as in the interests of
the company and road-network users, that you comply with the following guidelines:
(*) Licensed physician as defined In sacf/on 082.107
Moreover, I agree to familiarize and respect it.
On March 30,1999 United States Federal Motor Carrier Safety Regulation medical
requirements for Canadian drivers of commercial motor vehicles operating in the
United States were revised. | acknowledge there is no requirement for a completed
United States medical fitness report. This revision does require that a Canadian
driver must comply to the medical requirements of the province in which their
commercial drivers license is issued and that a medical fitness report is completed
on the frequency as required by license issuing province.
requirement to operate a commercial motor vehicle in the United States, that |
am not impaired to operate a commercial motor vehicle by any of the following :
I also agree to inform the company should my medical status change, and if any of
the above impairments are subsequently diagnosed to the level of affecting my fitness
to operate a commercial motor vehicle in the United States.
In accordance with 395.2 of the Federal Motor Carrier Safety Regulations,
Title 49 of the Code of Federal Regulations, as amended in a Final Rule issued
on October 23, 1987 (53 Fed. Reg. 41718), carriers and drivers are to includes
as “on duty” the time a driver spends :” (9) Performing any compensated work for
any non motor carrier entity”
| hereby certify that | have read the foregoing “Notice to drivers” and
understand that any time | spend performing any compensated work for a non
motor carrier entity must be included as “on duty time” under the federal
hours of service regulations.
I further certify that: (Check appropriate block)
In accordance with the provisions of Section 604(b)(2)(A) of the Fair Credit
Reporting Act, Public Law 90-508, as amended by the Consumer Credit Reporting Act
of 1996 (Title Il, Subtitle D, Chapter |, 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, and391.25 of Federal Motor
Carrier Safety Regulations.
(To be completed once a year)
The passenger who will have been authorized beforehand by the company. When this
authorization is granted for the United States, the passenger must not have criminal
record and must have an insurance cross-blue for the duration of the trip.
The driver, undersigned, commit themselves defraying The company for any loss,
material, monetary, any delay or disadvantage attached closely or by far to the
presence of the aforesaid passenger aboard vehicle.
The driver understands that The company will be able to retain any amount which it
considers necessary for ends of compensation of loss or damage. This reserve could
be carried out without obligation of setting in residence and will be regarded as
damage interests liquidated in advance. In the case of any additional amount, The
company will be able to directly proceed. The driver accepts as of signature of
present that any procedures will be judged in the legal district of
Will answer the following question :
If you have answered yes to the above question, you must provide documentation
proving you have successfully complied with the return-to-duty process as required
in Part 40, Subpart O. (You must provide proof of your S.A.P. evaluation, a negative
return-to-duty drug and/or alcohol test result, and all follow-up drug and/or alcohol
test results done in accordance with S.A.P. recommendation.) You must also provide any
other documents related to the referral, evaluation and follow-up process.
If you answered yes to the above question and did not complete the required S.A.P.
program, you hereby agree to complete this S.A.P. program.
(To be completed on the first day of service.)
(Proof of Repair)
as our representative, within the meaning of section 5.7 of the Regulation respecting
mechanical inspection and safety standards for road vehicles, so that he signs on our behalf
the vehicle inspection register in the event (On the Road) a defect is discovered on the
vehicle and the or the person normally designated by him are unable to sign this register.»
In accordance with Section 391.25 of U.S. Department of Transportation's FMCSR, all carriers shall, at least once every 12 months, review the driving record each of the drivers in their employ operating motor vehicles in the United States to ensure they comply with the minimum requirements of safe driving or are no longer qualified for driving a commercial vehicle (Section 391.15).
In reviewing a driving record, the motor carrier must consider any evidence that the driver has violated applicable provisions of the F.M.C.S.R. and the Transportation of Hazardous Materials Regulations. He must also consider the driver's accident record and any evidence that the driver has violated laws governing the operation of motor vehicles. He must give great weight to violations such as speeding, reckless driving and operation while under the influence of alcohol or drugs, that indicate that the driver has exhibited a disregard for public safety.
I certify that I have reviewed the driving record of the above mentioned driver in accordance with Section 391.25 of FMCSR, and that this driver :
(To be kept in employee's confidential file)
For exchange of information between previous employers regarding
382.301 - 382.405(f) - 382.413 — 40.25
With regard to the driver whose name appears in Part 1, during the past three (3) years:
This person was employed in a safety-sensitive function that required alcohol and controlled-substances testing specified by 49 CFR Part 40 (if NO, skip this section)
Any drug or alcohol testing information obtained from previous employers under $40.25 or other applicable DOT regulations is included in this information. **
** Amendments to the FMCSR effective April 29, 2004