Application Info

License Details

Current Address Details

Provide your employment history for last 3 to 7 years (if any)

Employment Details

Employment Details 1

Employment Details 2

Employment Details 3

Employment Details 4

Employment Details 5

Provide your traffic conviction and forfeitures history for last 3 years (if any). Please use None on each column if nothing to report.

Provide your traffic conviction and forfeitures history for last 3 years (if any). Please use None on each column if nothing to report.

Provide your traffic conviction and forfeitures history for last 3 years (if any). Please use None on each column if nothing to report.

Driving Experience

Class of Equipment

Experience - Others

Authorization for Driver and Criminal Records Searches

The Federal Motor Carrier Safety Regulations, Section 391.21 which covers Driver’s qualification and application for employment, requires the motor carrier to obtain a list of all motor vehicles violations for the last three (3) years.

In Ontario, this is known as Commercial Vehicle Operator Record Driver Abstract. It is company policy to obtain a list of both commercial and personal motor vehicle violations for each driver operating under its authorities, on a periodic basis.

As a condition of my employment/ contract, I hereby provide written authorization to obtain such information and to conduct periodic criminal searches as and when required.

This consent also extends to the verification of my driver license status. Information required to complete this inquiry is your driver license number, your date of birth and the province where license is issued. These requests will not affect or to be registered against your license in any way.

These searches would ensure that the driver has a valid commercial driver license and he is not prohibited to drive a commercial vehicle according to the governing laws and jurisdictions they work in.

I have read and understand the above conditions.

Release and Authorization to Contact Previous Employer

This form should be kept in an applicant’s file to document compliance with the request for the information from the previous employer.

Release and authorization to contact previous employer as required by 49 CFR 391.23

I, undersigned, hereby authorize you to release the following information for the purpose of investigation as required by 49 CFR 391.23 of the Federal Motor Carriers Safety Regulations. Information may include all employment information concerning my employment net, including written and oral assessments of my work performance, fitness and ability. You are released from all liability which may result from furnishing such information. I hereby authorize you to release the following information for the purpose of investigation.

DRIVER DATA SHEET

FOR CASUAL, NEW HIRES & TEMPORARY EMPLOYEES

Instructions:   Motor Carriers when using a driver for the first time or intermittently shall obtain from the driver a signed statement giving the total time on duty during the immediately preceding 14 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.

Hours Worked

Hours Worked

Annual Medical Declaration

On March 30, 1999, Transport Canada and U.S Federal Highway Administration (FHWA) entered into a reciprocal agreement regarding the physical requirement for Canadian driver of a commercial vehicle in the U.S., as currently contained in Federal Motor Carrier Safety regulations, Part 391.43, and vice-versa. The reciprocal agreement removes the requirement for a Canadian driver to carry a copy of medical examiner’s certificate indicating that the driver is physically qualified. (In effect, the existence of valid driver’s license issued by the province of Ontario is deemed to be proof that a driver is physically qualified to drive in the U.S.). However, FHWA will not recognize an Ontario license if the driver has certain medical conditions, and those conditions would prohibit him from driving in the U.S. A driver has to give a signed declaration that he is fit to drive in the US every year which is to be kept in his driver qualifications file.

The Qualifications of Drivers, Diabetes Standard final rule published on September 19, 2018 (83 FR 47486).

1   Medical history or clinical diagnosis of epilepsy
2   Obstructive sleep apnea (OSA)
3   Impaired hearing (A driver must be able to first perceive a forced whispered voice in the better ear at not less than 5 feet with or with the use of hearing aid, or does not have an average hearing loss in the better ear greater than 40 decibels at 500Hz, 1000Hz or 2000Hz with or without hearing aid when tested by an audiometric device calibrated to American National Standard Z24.5-1951).
4   Issued a waiver by the province of Ontario allowing me to operate a commercial motor vehicle pursuant to Section 20 or 21 of Ontario Regulation 340/94.
5   If W condition on my Ontario License, then I am considered as diabetic and will follow the below mentioned in USA.
6   RF 391.41(b)(3): To allow insulin use if 391.46 requirements meet.
a   49CFR 391.46: To indicate certification every 12 months if taking insulin.
b   49CFR 391.46: To outline regulatory requirements for certification if taking insulin.
7   Considering disqualified if Unstable insulin regimen is present.
a   Diabetes mellitus is not properly controlled.
8   Considered Permanent disqualified if severe non-proliferative diabetic retinopathy or proliferative diabetic retinopathy is diagnosed.
9   Carry prescribed medicine to take, must keep prescription all the time and will present upon inquiry.
10   Required to carry over the counter medicine, and I will provide documented proof of carrying the medicine.
11   Cognitive Impairment.
12   A disorder resulting in cognitive impairment that affects attention, judgement and problem solving, planning and sequencing, memory, insight, reaction time or visuospatial perception, and results in substantial limitation of the person’s ability to perform activities of daily living. Due to: Dementia Brain Injury / Tumor.
13.   Sudden Incapacitation.
14   A disorder that has a moderate or high risk of sudden incapacitation, or that has resulted in sudden incapacitation and that has a moderate or high risk of recurrence due to:
15   Seizure Alcohol/Drug Withdrawal Epilepsy Stroke Syncope Single episode not yet diagnosed.
16   Heart disease with pre-syncope/syncope/arrhythmia.
17   Narcolepsy with uncontrolled cataplexy or daytime sleep attacks.
18   Obstructive sleep apnea – Untreated or Unsuccessfully Treated with Apnea-hypopnea index (AHI) of greater than or equal to 30 with daytime sleepiness.
19   Hypoglycemia requires intervention of third party or produces loss of consciousness.
20   Uncontrolled diabetes or hypoglycemia.
21   Motor or Sensory Impairment.
22   A condition or disorder resulting in severe motor impairment that affects coordination, muscle strength and control, flexibility, motor planning, touch or positional sense. Due to:
23   Loss of Limb Spinal Cord Injury.
24   Visual Impairment Best corrected visual acuity below 20/50 with both eyes open and examined together.
25   Visual field less than 120 continuous degrees along the horizontal meridian, or less than 15 continuous degrees above and below fixation, or less than 60 degrees to either side of the vertical meridian, including hemianopia.
26   Diplopia within 40 degrees of fixation point (in all directions) of primary position, that cannot be corrected using prism lenses or patching.
27   Substance Use Disorder.
28   A diagnosis of an uncontrolled substance use disorder, excluding caffeine and nicotine, and patient is non-compliant with treatment recommendations.
29   Psychiatric Illness.
30   A condition or disorder currently involving any of the following: acute psychosis, severe abnormalities of perception, or patient has a suicidal plan involving a vehicle or an intent to use a vehicle to harm others

I have understood all the above mentioned and declaring that I have:

Further agree to inform Shaan Truck Lines immediately, should my medical status change, or if I can no longer certify the conditions described.

FORM 413/301

REQUEST FOR DRUG AND ALCOHOL TESTING INFORMATION FROM PREVIOUS EMPLOYERS in accordance with 49 CFR 382.413 and 49 CFR 40.25 AND FOR PRE- EMPLOYMENT in accordance with 49 CFR 382.301 (b)

PURPOSE OF THIS FORM: (A) Under 49 CFR 382.413 which refers to 49 CFR 40.25 of the DOT regulations, previous employers must provide information regarding the violations of the regulations, specifically, any alcohol tests with a result of 0.04 or greater, any verified positive drug tests and any refusals to be tested ( including verified adulterated or substituted drug test results), as well as information on whether the employee completed the required assessment and requalification provisions under the regulations in accordance with 49 CFR part 40 Subpart O. (B)

• Under 49 CFR 382.301 (b) a prospective employer is not required to administer a pre – employment drug test om hiring a driver if he/she can verify the prospective driver’s previous participation in a compliant testing program382.301(c)(1). An employer can exercise this exemption if he contacts the testing program and obtains the information below.
• Under 49 CFR 382.301(c) (2) an employer who hires a temporary or contract driver participating in a testing program administered by another entity must verify the driver’s participation in a complaint testing program. If a driver is used periodically, the information must be updated every 6 months.

as applied to our company for a safety- sensitive position as outlined in 49 CFR 382.107. In compliance with DOT regulations 49 CFR 382.413 CFR 40.25 and 382.301. We are hereby requesting information regarding this individual’s involvement with your company’s drug and alcohol testing program. A consent for the release of this information follows:

APPLICANT/DRIVER CONSENT

Designated Employer Representative:

In accordance with 49 CFR 382.405(f), by my signature below, I authorize you and/ or your third party administrative to release any and all information regarding drug and alcohol testing done on myself including any and all information on this form and responses to questions set out on this form, while in your employment, acting as your agent, under con WITH YOU, OR ACTING As your representative in any capacity during the preceding three years from the above date. This information is to be released to the prospective employer named below and/or to their Third-Party Administrator.

From:  Shaan Truck Lines, 60 Armstrong Ave, Georgetown, ON L7G 4R9
Ph: 905282-6000 x301 | Email: safety@shaantrucklines.com

I also understand that I have the right under 49 CFR 391.23 (i) and (j), to review information provided by previous employers: to have errors in the information corrected by the employer and to have that employer re-send the corrected information to the prospective employer, to have a rebuttal statement attached to the alleged erroneous information, if the previous employer and myself cannot agree on the accuracy of the information.

Carrier Name: Shaan Truck Lines

Any issues with the following:

Please check the following box and skip to section 2 below, if yes complete the following questions before proceeding to section 2:

General Consent for Full and Limited Queries of the Federal Motor Carrier Safety Administration (FMCSA) Drug and Alcohol Clearinghouse

Information is collected and disclosed in accordance with federal, provincial and municipal laws.

A Declaration of Criminal Record does not constitute a Certified Criminal Record by the RCMP and may not contain all criminal record convictions.
Applicants must declare all convictions for offences under Canadian federal law.

Do not declare the following:
- A conviction for which you have received a Record Suspension (formerly pardon) in accordance with the Criminal Records Act;
- A conviction where you were a "young person" under the Youth Criminal Justice Act;
- An Absolute or Conditional Discharge, pursuant to section 730 of the Criminal Code;
- An offence for which you were not convicted;
- Any provincial or municipal offence, and;
- Any charges dealt with outside of Canada.

Note that a Certified Criminal Record can only be issued based on the submission of fingerprints to the RCMP National Repository of Criminal Record.