returning sales reps and returning helper drivers sales reps and returning helper drivers 1....

Returning Sales Reps and Returning Helper Drivers

1. Certification of Violations/ Annual Review of Driving Record

2. MVR Release/Request Form

3. Certificate of Compliance

4. Driver Certificate of Other Compensated Work

5. Regulatory Agency Compliance Policy Statement

6. Drivers Statement of on Duty Hours

7. We must have received the results of annual drug screen

8. Legible copy of current drivers' license (Photo with Phone is great)

9. Copy of current medical card and long form if not on file

lO.Receipt of FMCSA handbook

11.Drivers Application (if not currently on file)

The safety office must have received all forms correctly completed prior to

being recertified to operate a Bonnie truck.

Stephen D. HarmonSafety Director

MOTOR VEHICLE DRIVER'SCertification of Violations/Annual Review of Driving Record

MOTOR CARRIER INSTRUCTIONS: Each motor carrier shall at least once every 12 months, require each driver it employs to prepare and furnish itwith a list of all violations of motor vehicle traffic laws and ordinances (other than violations involving only parking) of which the driver has beenconvicted, or on account of which he/she has forfeited bond or collateral during the preceding 12 months (Section 391.27). Drivers who have providedinformation required by Section 383.31 need not repeat that information on this form.

DRIVER REQUIREMENTS: Each driver shall furnish the list as required by the motor carrier above. If the driver has not been convicted of, or forfeitedbond or collateral on account of any violation which must be listed, he/she shall so certify (Section 391.27).

COMPLETED BY DRIVER - CERTIFICATION OF VIOLATIONS

NAME OF DRIVER: (PRINT) ID NUMBER

HOME TERMINAL (CITY AND STATE) DRIVER'S LICENSE NUMBE

DATE OF EMPLOYMENT

:R STATE EXPIRATION DATE

I certify that the following is a true and complete list of traffic violations required to be listed (other than those I haveprovided under part 383) for which I have been convicted or forfeited bond or collateral during the last 12 months.

(If you have had no violations, check the following box - | | None.)

DATE OFFENSE LOCATION TYPE OF VEHICLE OPERATED

If no violations are listed above, I certify that I have not been convicted or forfeited bond or collateral on account of anyviolation (other than those I have provided under Part 383) required to be listed during the past 12 months.

Date nf Certification Driver's Sianature

COMPLETED BY MOTOR CARRIER - ANNUAL REVIEW OF DRIVING RECORD

MOTOR CARRIER INSTRUCTIONS: Review the Certification of Violations listed above and other information described inSection 391.25 of the Federal Motor Carrier Safety Regulations. Complete the information requested below.

I have hereby reviewed the driving record of the above named driver in accordance with Section 391.25 and findthat he/she (check one):

I I Meets minimum requirements for safe driving I I Is disqualified to drive a motor vehicle pursuant to Section 391.25

[ I Does not adequately meet satisfactory safe driving performance

Action taken with driver

Reviewed by:Signature

Jamie PadgettDate

Transportation Compliance OfficerPrinted Name

Bonnie Plants, Inc.Title

1727 Hwy 223, Union Springs, AL 36089Motor Carrier Name Motor Carrier Address

MAINTAIN THIS DOCUMENT IN THE DRIVER'S QUALIFICATION KILE. THIS DOCUMENT MAY BE PURGED AFTER 3 YEARS FROM DATEOF EXECUTION.

© Copyright 2008 J.J. KELLER & ASSOCIATES. INC., Neenah. Wl USA • (800) 327-6868 • www.jjkeller.com 643-F 3585(11/08)

BONNIE PLANTS, INC.

Motor Vehicle Record ( MVR ) Release / Request Form

I understand that as a condition of operating any Bonnie Plants, Inc. Insured Vehicle,my Motor Vehicle Record will be requested. This information is used to ensure the safetyof employees and the general public.

I hereby authorize Bonnie Plant Inc. to access and evaluate my Motor Vehicle record. Iagree to provide whatever information is required in order to facilitate access.

Printed Name:_

Date:

Date of Birth:

Social Security Number:,

Drivers License Number and State of Issuance:

Date of Hire:

Signature:

Phone Number:

Alternate Phone Number:

Email:

Supervisor:

Motor Vehicle Driver's

CERTIFICATION OF COMPLIANCEWITH DRIVER LICENSE REQUIREMENTS

MOTOR CARRIER INSTRUCTIONS: The requirements in Part 383 apply to every driver whooperates in intrastate, interstate, or foreign commerce and operates a vehicle weighing26,001 pounds or more, can transport more than 15 people, or transports hazardousmaterials that require placarding.

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

DRIVER REQUIREMENTS: Parts 383 and 391 of the Federal Motor Carrier SafetyRegulations contain certain driver licensing requirements that you as a driver must complywith, including the following:

1) POSSESS ONLY ONE LICENSE: You, as a commerical vehicle driver, may notpossess more than one motor vehicle operator's license.

2) NOTIFICATION OF LICENSE SUSPENSION, REVOCATION OR CANCELLATION:Sections 391.15(b)(2) and 383.33 of the Federal Motor Carrier Safety Regulationsrequire that you notify your employer the NEXT BUSINESS DAY of anyrevocation or suspension of your driver's license. In addition, Section 383.31requires that any time you violate a state or local traffic law (other than parking),you must report it within 30 days to: 1) your employing motor carrier, and 2) thestate that issued your license (If the violation occurs in a state other than the onewhich issued your license). The notification to both the employer and the state mustbe in writing.

3) CDL DOMICILE REQUIREMENT: Section 383.23(a)(2) requires that yourcommercial driver's license be issued by your legal state of domicile, where youhave your true, fixed, and permanent home and principal residence and to whichyou have the intention of returning whenever you are absent. If you establish anew domicile in another state, you must apply to transfer your CDL within 30days.

The following license is the only one I will possess:

Driver's License No. State Exp. Date

DRIVER CERTIFICATION: I certify that I have read and understood the above requirements.

Driver's Name (Printed):

Driver's Signature: Date

Notes:(This lorm is not required for DOT compliance)

90-F 1617© Copyright 2008 JJ KELLER & ASSOCIATES, INC , Neenah, Wl USA (800) 327-6868 • wwwjjkeller.com Printed in the United States (REV 3/08)

DRIVER CERTIFICATION FOR OTHER COMPENSATED WORK

INSTRUCTIONS: When employed by a motor carrier, a driver must report to thecarrier all on-duty time including time working for other employers. The definition ofon-duty time found in Section 392 paragraphs (8) and (9) of the Federal Motor CarrierSafety Regulations includes time performing any other work in the capacity of, or in theemploy or service of, a common, contact or private motor carrier, also performing anycompensated work for any non-motor carrier entity.

Are you currently working for another employer? YESNO

At this time do you intend to work for another employer while YESNOstill employed by this company:

I hereby certify that the information given above is true and I understand that once Ibecome employed with this company, if I begin working for any additional employer(s)for compensation that I must inform this company immediately of such employmentactivity.

Driver's Signature Date

Witness:Company Representative Date

OUR ROOTS RUN DEEP.'

REGULATORY AGENCY COMPLIANCE POLICY STATEMENT

Bonnie Plants is committed to a policy of strict adherence to all local, state, and

federal laws.

As an associate of Bonnie Plants, I understand that I am expected and required to

adhere to all local, state, and federal laws and those specifically outlined in the

Federal Motor Carrier Safety Regulations of the U. S. Department ofTransportation.

I further understand that any deviation from the above policy will not be

tolerated and could result in disciplinary action up to and including termination.

I, , acknowledge receiptand understand the above policy statement.

Date:

Associate:

Witness:

DRIVER STATEMENT OF ON-DUTY HOURS(For Newly Hired Drivers)

INSTRUCTIONS: 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 immediatelyprecending? days and time at which such driver was last relieved from duty prior tobeginning work for such carrier. Rule 395.8(j)(2) Federal Motor Carrier SafetyRegulations NOTE: Hours for any compensated work during the preceding 7 days,including work for a non-moor carrier entity must be recorded on this form.

Driver Name (Print)

Social Security Number

Driver's License: State_

Class

Number

Endorsement(s) Restrictions(s)_

DAY

DATE

HOURSWORKED

1yesterday

2 3 4 5 6 7

TotalHours

I hereby certify that the information given above is correct to the best of my knowledge andbelief, and that I was last relived from work at

A.M.P.M.

TimeOn

Day Month Year

Drivers Signature Date

DRIVER'S APPLICATIONFOR EMPLOYMENT

Applicant Name Date of Application

Company

Address

City State Zip

In compliance with Federal and State equal employment opportunity laws, qualified applicants are considered for allpositions without regard to race, color, religion, sex, national origin, age, marital status, veteran status, non-job related

disability, or any other protected group status.

TO BE READ AND SIGNED BY APPLICANT

I authorize you to make such investigations and inquiries of my personal, employment, financial or medical history andother related matters as may be necessary in arriving at an employment decision. (Generally, inquiries regardingmedical history will be made only if and after a conditional offer of employment has been extended.) I hereby releaseemployers, schools, health care providers and other persons from all liability in responding to inquiries and releasinginformation in connection with my application.

In the event of employment, I understand that false or misleading information given in my application or interview(s)may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the Company.

I understand that information I provide regarding current and/or previous employers may be used, and those employer(s)will be contacted, for the purpose of investigating my safety performance history as required by 49 CFR 391.23(d) and(e). I understand I have the right to:

• Review information provided by previous employers;

• Have errors in the information corrected by previous employers and for those previous employers to re-send thecorrected information to the prospective employer; and

• Have a rebuttal statement attached to the alleged erroneous information, if the previous employer(s) and I cannotagree on the accuracy of the information.

Signature Date

FOR COMPANY USE

PROCESS RECORD

APPLICANT HIRED REJECTED

DATE EMPLOYED _ POINT EMPLOYED

DEPARTMENT CLASSIFICATION

(IF REJECTED, SUMMARY REPORT OF REASONS SHOULD BE PLACED IN FILE)

SIGNATURE OF INTERVIEWING OFFICER

TERMINATION OF EMPLOYMENT

DATE TERMINATED DEPARTMENT RELEASED FROM

DISMISSED VOLUNTARILY QUIT OTHER

TERMINATION REPORT PLACED IN FILE SUPERVISOR

This form is made available with the understanding that J. J. Keller & Associates, Inc.® is not engaged in rendering legal, accounting, or other professional services.J. J. Keller & Associates, Inc.® assumes no responsibility for the use of this form or any decision made by an employer which may violate local, state or federal law.

C Copyright 2011 J.J. KELLER & ASSOCIATES, INC.®, Neenah, WI • USA ]5F (Rev 1/11) 691(800) 327-6868 - www jnkellcr com • Printed in the United States

APPLICANT TO COMPLETE(answer all questions - please print)

Position(s) Applied forName

Last First

List your addresses of residency for the past 3 years.

Current Address

Social Security No.Middle

Street City

PhoneState Zip Code

Previous

How Long?

How Long?Addresses street

Street

Street

Do you have the legal right to work in the United States?

Date of Birth

City

City

City

Can you

State & Zip Code yr./mo.

How Long?State & Zip Code yr./mo.

How Long?State & Zip Code yr./mo.

provide proof of age?(Required for Commerical Drivers)

Have you worked for this company before?

Dates: From To

Reason for leaving

Are you now employed?

Who referred you?

Have you ever been bonded?(Answer only if a job requirement)

Where?

Rate of Pay Position

If not, how long since leaving last employment?

Rate of pay expected

Name of bonding company

Is there any reason you might be unable to perform the functions of the job for which you have applied [as described in theattached job description]?

If yes, explain if you wish.

EMPLOYMENT HISTORY

All driver applicants to drive in interstate commerce must provide the following information on all employersduring the preceeding 3 years. List complete mailing address, street number, city, state, and zip code.

Applicants to drive a commercial motor vehicle* in intrastate or interstate commerce shall also provide anadditional 7 years' information on those employers for whom the applicant operated such vehicle.(NOTE: List employers in reverse order starting with the most recent. Add another sheet as necessary.)

EMPLOYER

NAME

ADDRESS

CITY

CONTACT PERSON

STATE

WERE YOU SUBJECT TO THE FMCSRst WHILE EMPLOYED?

WAS YOUR JOB DESIGNATED AS A SAFETY-SENSITIVE FUNCTIONAND ALCOHOL TESTING REQUIREMENTS OF 49 CFR PART 40?

ZIP

PHONE NUMBER

DATE

FROM TOMO. YR MO YR.

POSITION HELD

SALARY/WAGE

REASON FOR LEAVING

n YES n NOIN ANY DOT-REGULATED MODE SUBJECT TO THE DRUG

n YES n N°PAGE 2 15F (Rev. 1/11) 691

EMPLOYMENT HISTORY (continued)

EMPLOYER

NAME

ADDRESS

CITY STATE

CONTACT PERSON



ZIP

PHONE NUMBER

DATE

FROM TOMO YR MO YRPOSITION HELD

REASON FOR LEAVING

D YES D NO

IN ANY DOT-REGULATED MODE SUBJECT TO THE DRUGn YES n NOEMPLOYER

NAME

ADDRESS

CITY STATE

CONTACT PERSON



ZIP

PHONE NUMBER

DATE

FROM TOMO YR MO YR.

POSITION HELD

SALARY/WAGE

REASON FOR LEAVING

D YES D NO

IN ANY DOT-REGULATED MODE SUBJECT TO THE DRUG

n YES n NOEMPLOYER

NAME

ADDRESS

CITY STATE

CONTACT PERSON



ZIP

PHONE NUMBER

DATE

FROM TOMO YR MO YR

POSITION HELD

SALARY/WAGE

REASON FOR LEAVING

D YES D NO

IN ANY DOT-REGULATED MODE SUBJECT TO THE DRUG

n YES n NOEMPLOYER

NAME

ADDRESS

CITY STATE

CONTACT PERSON



ZIP

PHONE NUMBER

DATE

FROM TOMO YR. MO YRPOSITION HELD

SALARY/WAGE

REASON FOR LEAVING


n YES n NOEMPLOYER

NAME

ADDRESS

CITY STATE

CONTACT PERSON



ZIP

PHONE NUMBER

DATE

FROM TOMO YR. MO YR.POSITION HELD

SALARY/WAGE

REASON FOR LEAVING


fj YES Q NO

* Includes vehicles having a GVWR of 26,001 Ibs. or more, vehicles designed to transport 16 or more passengers (including thedriver), or any size vehicle used to transport hazardous materials in a quantity requiring placarding.

t The Federal Motor Carrier Safety Regulations (FMCSRs) apply to anyone operating a motor vehicle on a highway in interstate

commerce to transport passengers or property when the vehicle: (1) weighs or has a GVWR of 10,001 pounds or more, (2) is

designed or used to transport 8 or more passengers (including the driver), OR (3) is of any size and is used to transport hazardousmaterials in a quantity requiring placarding.

PAGE 3 I 5 F (Rev

ACCIDENT RECORD FOR PAST 3 YEARS OR MORE (ATTACH SHEET IF MORE SPACE IS NEEDED) IF NONE, WRITE NONE

DATES

LAST ACCIDENT

NEXT PREVIOUS

NEXT PREVIOUS

NATURE OF ACCIDENT

(HEAD-ON, REAR-END, UPSET, ETC.) FATALITIES INJURIES

HAZARDOUS

MATERIAL SPILL

TRAFFIC CONVICTIONS AND FORFEITURES FOR THE PAST 3 YEARS (OTHER THAN PARKING VIOLATIONS) IF NONE, WRITE

NONE

LOCATION DATE CHARGE PENALTY

(ATTACH SHEET IF MORE SPACE IS NEEDED)

EXPERIENCE AND QUALIFICATIONS - DRIVER

Driver

licenses or

permits held

in the past

3 years

STATE LICENSE NO. CLASS ENDORSEMENT(S) EXPIRATION DATE

A. Have you ever been denied a license, permit, or privilege to operate a motor vehicle?

B. Has any license, permit, or privilege ever been suspended or revoked?

IF THE ANSWER TO EITHER A OR B IS YES, GIVE DETAILS

YES

YES

NO

NO

DRIVING EXPERIENCE CHECK YES OR NO

CLASS OF EQUIPMENT

STRAIGHT TRUCK D YES D NO

TRACTOR AND SEMI-TRAILER Q YES Q NO

TRACTOR - TWO TRAILERS D YES D NO

TRACTOR - THREE TRAILERS D YES D NO

MOTORCOACH - SCHOOL BUS DYES DNO ^*™"

MOTORCOACH - SCHOOL BUS DYES D NO Morethal115passengers

OTHER

CIRCLE TYPE OF EQUIPMENT

(VAN,TANK,FLAT,DUMP,REFER)




DATES

FROM(M/Y) TO(M/Y)

APPROX. NO. OF MILES

(TOTAL)

LIST STATES OPERATED IN FOR THE LAST FIVE YEARS:

SHOW SPECIAL COURSES OR TRAINING THAT WILL HELP YOU AS A DRIVER:

WHICH SAFE DRIVING AWARDS DO YOU HOLD AND FROM WHOM?

EXPERIENCE AND QUALIFICATIONS - OTHER

SHOW ANY TRUCKING, TRANSPORTATION OR OTHER EXPERIENCE THAT MAY HELP IN YOUR WORK FOR THIS COMPANY

LIST COURSES AND TRAINING OTHER THAN SHOWN ELSEWHERE IN THIS APPLICATION

LIST SPECIAL EQUIPMENT OR TECHNICAL MATERIALS YOU CAN WORK WITH (OTHER THAN THOSE ALREADY SHOWN)

CIRCLE HIGHEST GRADE COMPLETED: 1 2 3 4 5 6 7 8

LAST SCHOOL ATTENDED (NAME)

EDUCATIONHIGH SCHOOL: 1 2 3 4

(CITY, STATE)

COLLEGE: 1 2 3 4

TO BE READ AND SIGNED BY APPLICANTThis certifies that this application was completed by me, and that all entries on it and information in it are true andcomplete to the best of my knowledge.

Signature: Date:PAGE 4 15F (Rev. 1/11) 691

**Driver's Receipt

This issue of the FMCSR Pocketbook includes all revisions on or before June 8, 2015

I acknowledge receipt of this FEDERAL MOTOR CARRIER SAFETYREGULATIONS POCKETBOOK (347). In addition, I agree to familiarize myself withthe Federal Motor Carrier Regulations (FMCSR) of the U.S, Department ofTransportation, Parts 40, 380, 382, 383, 387, 390-397, 399 Subchapter B, Chapter 3, Title79 of the code of Federal Regulations, as contained therein.

DRIVER'S NAME (PLEASE PRINT) DATE

DRIVER'S SIGNATURE

SUPERVISOR OR CARRIER REPRESENTATIVE SIGNATURE

7/15

Note: This receipt shall be read and signed by the driver. A responsible companysupervisor or carrier representative shall countersign the receipt and place in the drive'squalification file.

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