LE GRANDE AFFAIRE
2590 LAFAYETTE STREET
SANTA CLARA, CA 95050
APPLICATION FOR EMPLOYMENT
ILLEGIBLE OR INCOMPLETE APPLICATIONS WILL NOT BE PROCESSED.
WE CONSIDER APPLICANTS FOR ALL POSITIONS WITHOUT REGARD TO RACE, COLOR, RELIGION, SEX, NATIONAL ORIGIN, AGE, MARTIAL STATUS, VETERAN STATUS, DISABILITY, OR ANY OTHER LEGALLY PROTECTED STATUS.

PLEASE ANSWER ALL QUESTIONS. IF NOT APPLICABLE, INDICATE “N.A.”.

Date of application: Position Applied For:
 
LAST NAME FIRST NAME
MIDDLE ADDRESS
STREET CITY
STATE ZIP CODE
TELEPHONE NUMBER (AREA CODE FIRST) DATE OF BIRTH
SOCIAL SECURITY NUMBER    
Residence: Previous 3 Years:
ADDRESS CITY
ADDRESS CITY
ADDRESS CITY
STATE ZIP CODE
STATE ZIP CODE
STATE ZIP CODE
ARE YOU A CITIZEN OF THE UNITED STATES? YES NO
WHEN CAN YOU BEGIN WORKING?
ARE YOU LEGALLY ELIGIBLE FOR
EMPLOYMENT IN THE UNITED STATES?
YES NO
IF NO, EXPLAIN:
ARE YOU AVAILABLE TO WORK ALL SHIFTS,
ANY DAY OF THE WEEK?
YES NO
IF NO, EXPLAIN:
HAVE YOU EVER BEEN EMPLOYED
WITH US BEFORE?
YES NO
IF YES, MONTH AND YEAR:
HAVE YOU EVER APPLIED FOR EMPLOYMENT
WITH US BEFORE?
YES NO
IF YES, MONTH AND YEAR:
DO YOU HAVE ANY RELATIVES WORKING
FOR THIS COMPANY?
YES NO
DEPT: RELATIONSHIP
HAVE YOU EVER BEEN CONVICTED
OF A FELONY?
YES NO IF YES, EXPLAIN AND DATES:
HAVE YOU EVER TESTED POSITIVE FOR
CONTROLLED SUBSTANCES OR ALCOHOL?
YES NO IF YES, EXPLAIN AND DATES:
IN CASE OF AN EMERGENCY, NOTIFY:

NAME
RELATIONSHIP
PHONE NUMBER
 
LE GRANDE AFFAIRE
APPLICATION
EMPLOYMENT HISTORY

Begin with your present or most recent employment and work backward in order, listing your employers for the last 10 years and including all full and part time employment. All time must be accounted for including military service, school, self-employment, and periods of unemployment. WE MUST HAVE TELEPHONE NUMBERS FOR ALL EMPLOYERS.
 
EMPLOYER: SUPERVISOR:
ARE YOU PRESENTLY EMPLOYED? YES NO
MAY WE CONTACT YOUR CURRENT EMPLOYER YES NO
ADDRESS:  
CURRENT EMPLOYERDATES OF EMPLOYMENT
 FROM
 TO
TELEPHONE:  
POSITION HELD:
RATE OF PAY:
TYPE OF EQUIPMENT OPERATED:  
NUMBER OF STATES DRIVEN IN
 
WHY DO YOU WANT TO CHANGE EMPLOYERS?

EMPLOYER: SUPERVISOR:
 
ADDRESS:  
SECOND TO LAST EMPLOYER
DATES OF EMPLOYMENT
 FROM
 TO
TELEPHONE:  
POSITION HELD:
RATE OF PAY:
TYPE OF EQUIPMENT OPERATED:  
NUMBER OF STATES DRIVEN IN
 
REASON FOR LEAVING:
EMPLOYER: SUPERVISOR:
 
ADDRESS:  
THIRD TO LAST EMPLOYER
DATES OF EMPLOYMENT
 FROM
 TO
TELEPHONE:  
POSITION HELD:
RATE OF PAY:
TYPE OF EQUIPMENT OPERATED:  
NUMBER OF STATES DRIVEN IN
 
REASON FOR LEAVING:
EMPLOYER: SUPERVISOR:
 
ADDRESS:  
FOURTH TO LAST EMPLOYER
DATES OF EMPLOYMENT
 FROM
 TO
TELEPHONE:  
POSITION HELD:
RATE OF PAY:
TYPE OF EQUIPMENT OPERATED:  
NUMBER OF STATES DRIVEN IN
 
REASON FOR LEAVING:
                                                     LE GRANDE AFFAIRE
                                                  EMPLOYMENT HISTORY
EMPLOYER: SUPERVISOR:
 
ADDRESS:  
FIFTH FIFTH TO LAST
DATES OF EMPLOYMENT
 FROM
 TO
TELEPHONE:  
POSITION HELD:
RATE OF PAY:
TYPE OF EQUIPMENT OPERATED:  
NUMBER OF STATES
DRIVEN IN
 
WHY DO YOU WANT TO CHANGE EMPLOYERS?
EMPLOYER: SUPERVISOR:
 
ADDRESS:  
SIXTH FIFTH TO LAST
DATES OF EMPLOYMENT
 FROM
 TO
TELEPHONE:  
POSITION HELD:
RATE OF PAY:
TYPE OF EQUIPMENT OPERATED:  
NUMBER OF STATES
DRIVEN IN
WHY DO YOU WANT TO
CHANGE EMPLOYERS?
 
EDUCATION
LIST ANY EDUCATION, VOCATIONAL, ON-THE-JOB, OR OTHER TRAINING YOU HAVE RECEIVED WHICH YOU WOULD LIKE TO BE CONSIDERED IN DETERMINING YOUR QUALIFICATIONS FOR THE POSITION YOU ARE APPLYING FOR.
CHECK THE HIGHEST GRADE COMPLETED: 7 8 9 10 11 12
COLLEGE:
1 2 3 4
 
SCHOOL NAME AND ADDRESS OF SCHOOL MAJOR COURSE OF STUDY DATES ATTENDED
FROM              TO
LIST DIPLOMAS
HIGH
NAME
CITY
STATE
COLLEGE
NAME
CITY
STATE
TRADE
NAME
CITY
STATE

EMPLOYMENT QUESTIONNAIRE
LeGrande Affaire Limousine Service, Inc. appreciates your interest and inquiry for employment. As the industry leader in the Bay Area, we have set, established and perform to set standards within the company. This questionnaire is designed to help us understand your desires and capabilities, along with providing information which allows us to determine the areas you are best qualified to perform and advance within. Answer all of the questions completely and honestly. If there is any doubt as to what your answer should be, use the answer that first came to mind. If you have any uncertainty about any of the questions, ask for clarification from the person who gave you the application and questionnaire. Your honesty and thoroughness in answering these questions will not only benefit us, but most importantly you.
 
1. Are you looking for full or part time work?
2. Which position are you applying for?
3. Which position is your secondary choice?
4. LeGrande Affaire Limousine Service, Inc. operates around the clock 365 days per year.
  • The sales department operates from 8AM until 11PM Monday through Saturday and from 9AM until 9PM on Sundays.
  • The chauffeurs operate 24 hours around the clock.
  • The mechanical department operates from 8AM until 6PM Monday through Friday.
  • The detail department operates from 8AM until 5PM Monday through Friday, and from 6AM until 3PM on Saturday and Sunday.
List as accurately as possible the hours you are available to work:
Sales department  
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
All other departments  
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
5. Do you consider yourself a day
person or night person?
6. Briefly summarize your work experience from your first job until your most recent.
     
7. List some of the details that you have been responsible for in previous jobs.
     
8. Are you a detail oriented person?
Yes 
  No   Sometimes
Explain:
9. List the qualities that you posses that will help you be successful in the position that you are applying for:
10. List any qualifications and professional experiences that would help you in the position that you are applying for:
11. List any advantages associated with the position that you are applying for:
12. list any disadvantages associated with the position that you are applying for:
13. Do you take pride in your work?
Yes 
  No  
Sometimes
Explain:
14. Where do you see yourself five (5) years from now professionally and personally:
15. How does working in the position that you are applying for fit into your long term plans?
16. Please rate yourself in the following categories. The scale is 1 - 10 with 10 being the highest. Rate yourself with the first answer that comes to mind.
Honesty
Loyalty
Common sense
Positive attitude
Sense of humor
Team player
Goal oriented
Customer relations
Ability to handle stress
Driving ability
Defensive driving
Fun to be with
Coachable
Leadership
Self starter
Reliability
Aggressiveness
Consistency
Learning curve
Organization
Loner
Professionalism
Sense of timing
Sense of direction
Ability to plan
Ability to use a map
Cleanliness
Ability to coach
Motivation
Follow through
17. Explain why LeGrande Affaire Limousine Service, Inc. should consider you above other candidates who have applied for employment?
18. List what you believe are important to keep you satisfied and stimulated in your career:
19. List what you believe can keep you from being satisfied and stimulated in your career:
20. List what you believe to be motivating factors for you personally and professionally:
21. Are you looking for career advancement? Yes     No
 
Unsure
Explain:
22. Are you available to work from a remote location? Yes No
Explain:
23.Have you ever been convicted of a misdemeanor? Yes No
Have you ever been convicted of a felony? Yes No
Explain a yes answer to either question:


ANSWER THE FOLLOWING QUESTIONS ONLY
IF YOU ARE APPLYING FOR A CHAUFFEUR POSITION

1. Number of hours of sleep that you require:
2. Describe your sense of direction:
3. Have you ever been employed as a professional driver or chauffeur? Yes     No    
If yes, explain in what capacity and for whom and how long:
4. What class license do you possess?
A
   
B
   
C
Other
   
5. Do you have a passenger endorsement for your license? Yes     No    
6. Do you have reliable transportation? Yes     No    
Make of vehicle Model
Year
7. Explain why you are interested in becoming a professional chauffeur:
8. Explain any advantages or disadvantages you associate with being a professional chauffeur:
9. Explain how working as a professional chauffeur would fit into your plans:
10. Please rate your knowledge of the roadways and freeways in the following areas. The scale is 1 - 10 with 10 being the highest. Rate yourself with the first answer that comes to mind.
San Francisco
Napa
San Jose
Carmel
Fremont
Oakland
Monterey
Bay Area overall
11. Do you have commitments or limitations that would interfere with working:
Late evenings: Yes No Sometimes
Early mornings: Yes No Sometimes
Working overnight charters: Yes No Sometimes
Explain:
12. Do you own or are you willing and able to purchase these items:
Tuxedo
Yes
No
Already own
Brief Case
Yes
No
Already own
Polaroid camera
Yes
No
Already own
Thomas Guide
Yes
No
Already own
Cellular phone
Yes
No
Already own
13. Describe what you perceive to be the duties of a professional chauffeur:
14. What do you believe are the three most important responsibilities performed by a chauffeur:
a)
b)
c)
15. Describe how you perceive airport service to be performed by a chauffeur:
16. Have you applied with any other limousine company for employment? Yes No
If yes, which company and where is the interview process:
17. Explain why you choose to Apply to LeGrande Affaire Limousine Service, Inc.:
18. Do you have any comments or statements that you wish to express?

FOR OFFICE USE ONLY

 

Interviewed by: Date:

Comments:

Dress: Ability:

Approach: Advancement potential:

2nd Interview by: Date:

Comments:

Dress: Ability:

Approach: Advancement potential:

3rd Interview with General Manager: Date:

Hired: Yes: No: Reason:

Department of Hire: Position of Hire: FT or PT:

Start Date: Wages / Salary: Benefits:

General Managers Comments:

 

Signature of the General Manager: Date:

 

IF YOU ARE APPLYING FOR A CHAUFFEUR POSITION,
PLEASE COMPLETE THE FOLLOWING PAGES


PLEASE BE CERTAIN TO COMPLETE ALL OF THE INFORMATION
TO THE BEST OF YOUR ABILITY WHEN
COMPLETING THIS APPLICATION


ITEMS TO BE ENCLOSED WITH THIS APPLICATION:

COPY OF CALIFORNIA DRIVERS LICENCE
COPY OF SOCIAL SECURITY CARD
CURRENT D.M.V. PRINTOUT (MRV) THAT IS CURRENT
(WITHIN THE LAST 30 DAYS)
COPY OF PASSPORT (IF AVAILABLE)
 
AN EQUAL OPPORTUNITY EMPLOYER
 
LE GRANDE AFFAIRE
APPLICATION DRIVING RECORD
(TO BE COMPLETED BY DRIVER, SALES, OR MANAGEMENT APPLICANTS)
 
HAS YOUR LICENSE EVER BEEN SUSPENDED OR REVOKED? Yes No IF YES, EXPLAIN:
HAVE YOU EVER BEEN CONVICTED OF DRIVING UNDER THE INFLUENCE OF ALCOHOL OR DRUGS? Yes No IF YES, EXPLAIN:  
DO YOU POSSESS A
COMMERCIAL DRIVERS LICENSE:
CLASS: ENDORSEMENTS?
ANY RESTRICTIONS?
DRIVERS LICENSE NUMBER: STATE: EXPIRATION DATE:
LIST ALL DRIVERS LICENSES HELD IN THE PAST THREE (3) YEARS
STATE
LICENSE NUMBER
TYPE
EXPIRATION DATE
TRAFFIC CONVICTIONS AND FORFEITURES
LIST ALL TRAFFIC CONVICTIONS, FORFEITURES OR SUSPENSIONS OF A LICENSE IN A MOTOR VEHICLE (OTHER THAN PARKING) FOR THE LAST 3 YEARS. IF NONE, WRITE NONE.
DATE
STATE
CHARGE
FOR SPEED LIST M.P.H. OVER LIMIT
PENALTY
 
ACCIDENT RECORD

LIST ALL ACCIDENTS/INCIDENTS YOU HAVE BEEN INVOLVED IN WHILE OPERATING A TRUCK, CAR, MOTORCYCLE, OR OTHER MOTORIZED VEHICLE INCLUDING PROPERTY DAMAGE. INCLUDE ALL ACCIDENTS/INCIDENTS WHETHER YOUR AT FAULT OR NOT FOR THE LAST 3 YEARS. IF NONE, WRITE NONE.

DATE
NATURE OF ACCIDENTHEAD-ON,
REAR-END, ROLL OVER, ETC.
WERE YOU AT FAULT
FATALITIES
INJURIES
 
REQUEST FOR INFORMATION
FROM PREVIOUS EMPLOYER

LE GRANDE AFFAIR
2590 LAFAYETTE ST.
SANTA CLARA, CA 95050
PHONE- 408-988-4884
FAX-408-986-1558
COMPANY:
ADDRESS:
CITY:
STATE:
ZIP:
PHONE:
FAX:
Name of Applicant:
Social Security Number:
_____________________________
Signature of Applicant
______________________
Date
 
JOB APPLIED FOR: LIMO DRIVER
_________________________________________________________________________
Previous Employer to Fill-out Within 10 days as per D.O.T.
1. This applicant lists dates of employment with your firm from: To:
If incorrect, please list dates:    
2. Did applicant drive a commercial motor vehicle for you company: Yes No Type:  
3. Was applicant a CDL DRIVER? Yes No What CDL Class?     A B   C
4. Job classification with your company:   
5. Number of accidents while employed with your company and/or the previous three years, as defined in part 390.5:
6. Why did employee leave your company: Resigned Discharged Laid-Off
7. Would you re-employ this person? Yes No Upon Review
8. Has applicant had any Hours-Of-Service violations that resulted in an Out-Of-Service order in the last three years? Yes No
 
Have any tests been conducted on the applicant in the last 3 years for:
Alcohol: Yes No
Controlled Substances:  
Yes No
 
IN THE PREVIOUS THREE YEARS HAS THE APPLICANT:
1. Tested 0.04 B.A.C. or greater on Alcohol Testing? Yes No
if yes, dates:
2. Tested POSITIVE on Controlled Substances? Yes No
if yes, dates:
3. Has applicant REFUSED any Alcohol Testing? Yes No
if yes, dates:
4. Has applicant REFUSED any Controlled Substance Testing? Yes No
if yes, dates:
5. Other violations of DOT agency drug / alcohol testing regulations? Yes No
if yes, dates:
6. Any POSITIVE Pre-employment test results in past history? Yes No
if yes, dates:
7. Did you ever receive any information from a previous employer Yes No
if yes, dates:
    that the individual violated any DOT drug/alcohol regulations            
8. Did applicant fail to undertake or complete a rehabilitation program Yes No    
    recommended by a SAP under part 382.605?            
9. Did applicant misuse alcohol or use of drugs after completing Yes No    
    a SAP referral program?            
Reason for leaving:
 
_____________________________________________________            ___________________________________        _____________
Signature of person providing information                         Title              Date
 
Revised 4/8/04        Was the above a verbal response? YES NO
LE GRANDE AFFAIRE
2590 LAFAYETTE STREET
SANTA CLARA, CA 95050
PHONE – 408-988-4884
FAX – 408-986-1558
RELEASE OF INFORMATION
REGARDING CONTROLLED SUBSTANCE AND ALCOHOL TESTING RESULTS / PREVIOUS EMPLOYMENT/ COMMERCIAL DRIVING EXPERIENCE/SAFETY PERFORMANCE HISTORY
APPLICANT NOTE: This document must be returned with your completed and signed application.
 
I hereby acknowledge that LE GRANDE AFFAIRE will request the following information from any prior employer or any of their respective agents and employees as required by 382.413.
1. Alcohol test result with a breath alcohol concentration of 0.04 or greater?
2. Positive drug test results?
3. Refusals to submit to a required alcohol or drug test?
4. Other violations of DOT agency drug and alcohol testing regulations?
5. With respect to any employee who has violated a DOT drug and alcohol regulation, documentation of the employee’s successful
    completion of DOT return-to-duty requirements, including follow-up tests?
6. Any positive pre-employment controlled substance tests and dates of such tests?
7. Information received by a previous employer regarding violations of the drug & alcohol regulations.
8. Did applicant fail to undertake or complete a rehabilitation program recommended by a SAP under part 382.605.
9. Did applicant misuse alcohol or use drugs after completing a SAP referral program

I hereby authorize anyone to furnish LE GRANDE AFFAIRE any information as may be required regarding my driving experience, accident history as defined in 390.5 and clarified in 391.23(d)(2), safety performance history, employment history, personnel record, and/or character without recourse. I understand that if qualified, any misrepresentation or false statement on my driving application revealed at a later date shall be considered sufficient cause for disqualification. I also understand this release in no way assures the applicant will be qualified as a commercial driver for LE GRANDE AFFAIRE
 
I hereby knowingly and voluntarily release all persons and entities from any and all claims or liabilities for releasing information described in this form to those identified in the preceding paragraphs. Also the previous employer is covered under 391.23 with limited liability. This is outlined in section 4014 of TEA-21 Pub. L. 105-178, 112 Stat. 107, 409, June 9,1998. Congress created a limitation on liability to protect motor carriers, their agents and insurers from being found liable because they supplied and used driver safety performance history records in the hiring decision process.
 
I understand that my refusal to sign this release will disqualify me from obtaining a commercial driving position with LE GRANDE AFFAIRE. I certify that I have read, understand and agree to all of the provisions of this form.
 
SIGNATURE: _____________________________________________________________
PRINT NAME: ____________________________________________________________
DATE: ________________________  SOCIAL SECURITY NUMBER: _________________
 
Under the HazMat Act all inquires must be responded to within 15 days. Responses are required even in the absence of data on accidents, or alcohol and controlled substances abuse. Part 393.23(g)(1) and 390.5 of the FMCSR clarify this rule. Carriers that fail to respond to this request are subject to fines and civil penalties prescribed in Appendix B paragraph (a)(1)(3) to part 386 of the FMCSR. The information requested is for the previous three-year period as required under the HazMat Act. This includes alcohol and controlled substance test information for the previous 3 years. A legal liability also is created by this rule for previous employers who fail to provide data. Previous employers who fail to provide the required driver safety performance history information may ultimately be found liable if the requesting motor carrier hires an unsafe driver without receiving the requested history and the driver is involved in an accident.
 
LE GRANDE AFFAIRE

APPLICANT CERTIFICATION

HOW DID YOU LEARN ABOUT US?
NEWSPAPER FRIEND WALK-IN TRADE MAGAZINE RELATIVE
DRIVER RECOMMENDED BY? __________________________________________________________________________
OTHER: _______________________________________________________________________
 
 
I hereby certify that all questions answered are correct and authorize LE GRANDE AFFAIRE to contact my former employers, references furnished, and all other sources that they see fit in order to verify the facts and information furnished with regard to my character and qualifications. Included in these qualifications will be the appropriate documents furnished by me verifying citizenship or valid authority to work in the United States. These will be furnished in conjunction with the immigration reform and control act of 1986 and/or other applicable laws. In addition, I understand that a pre-employment physical, controlled substance screening, and breath alcohol tests may or may not be preformed and will be part of the determination of my ability to perform in the position for which I am applying. I understand that the completion of this form or any other application form of the company does not assure me a position with said company or obligates the company in any way. This application for employment shall be considered active for a period of time not to exceed 45 days. Any applicant wishing to be considered for employment beyond this time period should inquire as to whether or not applications are being accepted at that time. I hereby understand and acknowledge that, unless otherwise defined by applicable law, any employment relationship with this organization is of an “at will” nature, which means that the employee may resign at any time and the employer may discharge employee at any time with or without notice or cause. It is further understood that this “at will” 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 further understand that this application is not nor is it intended to be a contract of employment and that any employment relationship established between the applicant and the company may be terminated at the will of either the applicant or the company. Should any employment relationship occur, I understand that I am required to abide by all the rules and regulations of the company. I understand that any misleading, incorrect, or omitted statements may render this application void, and, if employed, would be cause of immediate discharge. I CERTIFY THAT THIS APPLICATION WAS COMPLETED BY ME, AND ALL ENTRIES ON IT AND INFORMATION IN IT ARE TRUE AND COMPLETE TO THE BEST OF MY KNOWLEDGE. I also understand and agree that any conduct which would have been reason for my discharge can and will be used against me by LE GRANDE AFFAIRE even if it is acquired after my employment ceases. I agree to submit a urine sample and/or specimen for testing and agree to breath alcohol tests for the purpose of screening for pre-employment medical qualifications and thereafter as warranted by LE GRANDE AFFAIRE policy or Federal Regulatory agencies. I agree to submit to blood testing for controlled substances and alcohol testing if it becomes necessary. I authorize any and all previous employers to disclose any employment history and controlled substance and alcohol test results upon request.
 
DATE: ______________________________     X     ____________________________
        SIGNATURE OF APPLICANT
 
As a prospective employer, we must ask any applicant for a driving position with our company whether he/she has tested positive, or refused to test, on any pre-employment drug or alcohol test administered by an employer to which the applicant applied for, but did not obtain, “safety-sensitive transportation work” (driving a commercial motor vehicle) during the past two years.
 
YES, I HAVE TESTED POSITIVE FOR DRUGS/ALCOHOL, OR REFUSED TO TAKE A PRE-EMPLOYMENT DRUG/ALCOHOL
  TEST IN THE TWO YEARS PRECEDING THE DATE OF THIS APPLICATION.
NO, I HAVE NOT TESTED POSITIVE FOR DRUGS/ALCOHOL, OR REFUSED TO TAKE A PRE-EMPLOYMENT DRUG/ALCOHOL
  TEST IN THE LAST TWO YEARS PRECEDING THE DATE OF THIS APPLICATION.

Our company policy is zero tolerance for violations of the controlled substance and/or alcohol regulations. Any positive tests (pre-employment, random, post-accident) will result in this application being denied.
This certifies that all information therein is true and complete to the best of my knowledge; I also understand that misrepresentation or omission of information or facts may result in my rejection or dismissal.
______________________
________________________
DATE
   APPLICANT SIGNATURE
LE GRANDE AFFAIRE

DECLARATION OF EMPLOYMENT STATUS

 
Under the Federal Motor Carrier Safety Regulations companies are required to verify the employment background of all prospective drivers for the preceding three (3) years. You have advised that you were unemployed or self-employed during the time period shown below. This form is designed to enable you to account for that period of your employment history, or period when you were not employed, which cannot be verified by any other means. In the section below, please fill in the dates and describe your activities during that time.
DATES: FROM ____________________________     TO  ______________________________
                                   MONTH / YEAR                                   MONTH / YEAR
 
During the period specified I was engaged as follows:
 
I also confirm that during that period, the statements I have checked below are true:
 
1. I was not employed in any capacity on a full-time or regular part-time basis.
2. I was self-employed.
3. I did not collect unemployment benefits during this time.
4. I was not convicted of a crime or felony involving a motor carrier or any aspect of the trucking industry.
5. I was not involved in a motor vehicle accident of any type.

The two people listed below, neither of whom is related to me in any manner, can verify the above information. I hereby authorize you to contact them and request that information, and authorize them to release that information to you.

Names, addresses and telephone numbers:

______________________________
__________________________
                    SIGNATURE:
                 DATE:
THIS FORM CAN BE USED TO ACCOUNT FOR UP TO 60 DAYS UNEMPLOYMENT ONLY. ANY LONGER PERIODS REQUIRE DOCUMENTED PROOF.
 
LE GRANDE AFFAIRE

CERTIFICATION OF COMPLIANCE
WITH DRIVER LICENSE REQUIREMENTS

 
MOTOR CARRIER INSTRUCTIONS: The requirements in Part 383 apply to every driver who operates in intrastate, interstate, or foreign commerce and operates a vehicle weighing 25,001 pounds or more, can transport more than 15 people, or transports hazardous materials that require placarding.

The requirements in Part 391 apply to every carrier who operates in interstate commerce and operates a vehicle weighing 10,001 pounds or more, can transport more than 15 people, or transports hazardous materials that require placarding.

DRIVER REQUIREMENTS: Parts 383 and 391 of the Federal Motor Carrier Safety Regulations contain some requirements that you as a driver must comply with. These requirements are in effect as of July 1, 1987. They are as follows:


1) POSSESS ONLY ONE LICENSE: You, as a commercial vehicle driver, may not possess more than one motor vehicle operator's
license.
     If you have more than one license, keep the license from your state of residence and return the additional licenses to the states that
     issued them. DESTROYING a license does not close the record in the state that issued it. You must notify the state issuance if a
     license has been lost, stolen, or destroyed and close your record by notifying the State of issuance that you no longer want to be
     licensed by that state.

2) NOTIFICATION OF LICENSE SUSPENSION, REVOCATION OR CANCELLATION: Section 392.42 and 383.33 of the Federal Motor Carrier Safety Regulations require that you notify your employer the NEXT BUSINESS DAY of any revocation or suspension of your driver's license. In addition, Section 383.31 requires that any time you violate a state or local traffic law (other than parking), you must report it within 30 days to:

A- Your employing motor carrier
B- The state that issued your license (if the violation occurs in a state other than the one which issued your license)
 
The following license is the only one I will possess:
Drivers License No. State Exp. Date
DRIVER CERTIFICATION: I certify that I have read and understand the above requirements.
Driver's name (Printed): ______________________________________ 
Driver's signature:         ________________________     Date: ________
 
LE GRANDE AFFAIRE

AUTHORIZATION LETTER FOR THE RELEASE OF MEDICAL RECORD INFORMATION

 
I, ________________________________________________________________
hereby authorize _________________________________  (doctor holding the medical records) to release to
LE GRANDE AFFAIRE the following medical information from my personal medical records:
 
Copy of my Medical Examination Report (long form physical) and/or;
Verification of the date and blood pressure from my Medical Examination Report (long form physical) and/or
Any information relating to my physical condition as it relates to my Medical Examination Report (long form physical) and my ability to operate a commercial vehicle under FMCSA Regulations Part 391.41, 391.43, 391.45.
 
I give my permission for this medical information to be used only for the purpose of satisfying Federal Regulations and for employment purposes, but I do not give my permission for any other use or re-disclosure of this information.
 
____________________________________
____________________________________
signature
printed name
 
DATE _____________________________________
 
After this page is used to help verify the drivers long form physical, please put into personnel file
 
 
LE GRANDE AFFAIRE

DRIVERS RECEIPT OF SAFETY REGULATIONS HANDBOOK

 
I acknowledge receipt of the Federal Motor Carrier Safety Regulations Pocketbook (OSR-7A). In addition, I agree to familiarize myself with the Federal Motor Carrier Safety Regulations (FMCSR) of the U.S. Department of Transportation, parts 383, 387, 390-397 as contained therein. This issue of the FMCSR Pocketbook includes all revisions issued on or before:
 
Date of book: _________________________________
 
Drivers Signature: _____________________________ Date: _______________________
 
Company: LE GRANDE AFFAIRE
 
COMPANY REPRESENTATIVE SIGNATURE: _____________________________________
 
*****************************************************************
Note: This receipt shall be read and signed by the driver. A responsible company representative shall sign the receipt and
place it in the driver's qualification file.
*****************************************************************
 
LE GRANDE AFFAIRE

DRIVER RIGHTS OF INFORMATION REBUTTAL

 
The prospective employer must expressly notify drivers with DOT regulated employment during the preceding three years that he/she has the following rights regarding the investigative information that will be provided to the prospective employer pursuant to paragraphs (d) and (e) of 391.23 (i)(1).
 
(i) The right to review information provided by previous employers;
(ii) The right to have errors in the information corrected by the previous employer and for that previous employer to re-send the
  corrected information to the prospective employer;
(iii) 1. The right to have a rebuttal statement attached to the alleged erroneous information, if the previous employer and the driver
      cannot agree on the accuracy of the information.
  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.
(i) 1. Drivers wishing to request correction of erroneous information in records received pursuant to paragraph (i) of this section must
    send the request for the correction to the previous employer that provided the records to the prospective employer,
  2. After October 20, 2004, the previous employer must either correct and forward the information to the prospective motor carrier employer, or notify the driver within 15 days of receiving a driver’s request to correct the data that it, does riot agree to correct the data. If the previous employer corrects and forwards the data as requested, that employer must also retain the corrected information as part of he driver’s safely performance history record and provide it to subsequent prospective employers when requests for this information are received. If the previous employer corrects the data and forwards it to the prospective motor carrier employer, there is no need to notify the driver.
  3. Drivers wishing to rebut information to records received pursuant to paragraph (i) of this section must send rebuttal to the previous employer with instructions to include the rebuttal in that driver’s safety performance history.
  4. After October 29, 2004, within five business days of receiving a rebuttal from a driver, the previous employer must:
  (i) Forward a copy of the rebuttal to the prospective motor carrier employer.
  (ii) Append the rebuttal to the driver’s information in the carrier’s appropriate file, to be included as part of the response for any subsequent investigating prospective employers for the duration of the three-year data retention requirement,
  5. The driver may submit a rebuttal initially without a request for correction, or subsequent to a request for correction,
  6. The driver may report failures of previous employers to correct information or include the driver’s rebuttal as part of the safety performance information, to the FMCSA following procedures specified in § 386.12.
  (k) 1. The prospect lye motor carrier employer must use the information described in paragraphs (d) and (e) of this section only as part of deciding whether to hire the driver
  2. The prospective motor carrier employer, its agents and insurers must take all precautions reasonably necessary to protect the records from disclosure to any person not directly
involved in deciding whether to hire the driver. The prospective motor carrier, it’s agents and insurers must take all precautions reasonably necessary to protect the records from disclosure to any person not directly involved in deciding whether to hire the driver. The prospective motor carrier employer may not provide any alcohol or controlled substances information to the prospective motor carrier employer’s insurer.
 
DRIVER RIGHTS OF INFORMATION REBUTTAL


LE GRANDE AFFAIRE

DRIVER RIGHTS OF INFORMATION REBUTTAL

 
(i) 1. No action or proceeding for defamation, invasion of privacy, or interference with a contract that is based on the furnishing or use of information in accordance with this section may he brought against
(ii) A motor carrier investigating the information described in paragraphs (d) and (c) of this section, of an individual under consideration for employment as a commercial motor vehicle driver,
(iii) A person who has provided such information; or
(iv) The agents or insurers of a person described in paragraph (I)(1) or (ii) of this section, except insurers are not granted a limitation on liability for any alcohol and controlled substance information.
  2. The protections in paragraph (l)(1) of this section do not apply to persons who knowingly furnish false information or who are not in compliance with the procedures specified for these investigations.
 
I acknowledge I have read the above driver rights of rebuttal and understand my rights as stated.
 
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Signature
Printed Name
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Date
 
THIS MUST BE GIVEN TO THE APPLICANT PRIOR TO ANY HIRING DECISION