Employment Application Form

NEWCOMB WAREHOUSE, INC.
3606 Grandview Avenue
Muscatine, IA 52761
Ph.: (563) 263-7661 Fax: (563) 263-2123
Newcomb Warehouse, Inc. is a common truckload motor carrier based in Muscatine, IA. We started business in July of 1994 as a warehousing operation, and began OTR trucking operations in January 1997 with the acquisition of F.W. Newcomb Trucking, Inc. Newcomb Warehouse currently dispatches 20 company owned Freightliner power units.

We have 48-state authority, transporting general commodities with 53’ dry vans and reefers, totaling over 35 trailers in all. We have in-house brokerage capabilities to handle overflow shipments we are contracted to transport for our local shipper base when the volume exceeds our carrier capacity.

Company drivers are paid 21% of the gross load revenues* on all shipper derived traffic, in addition to stop-off and driver assist pay (when applicable). Drivers are eligible to earn an additional 4% safety performance/incentive bonus, after 90 days of employment. Newcomb continually monitors its carrier rates, and actively reviews and negotiates with it’s shippers to assure fair compensation for our services.

Payroll is generated weekly, to drivers having submitted completed trip paperwork by the cutoff day. Drivers are required to carry a working cell phone for dispatch purposes. Newcomb will reimburse $25 per month to help defray the cost of a driver’s phone plan.

After 90 days of continuous employment, all full time driver employees may also elect to participate in our major medical/prescription and dental plan for a cost of $160.00 per month. Family coverage is available for additional premiums, at our groups rates. A matching funds 401(k) plan is available after 1 year of employment. Premiums and contributions for both of these programs are made on a pre-tax basis.

Thank you for your interest in Newcomb Warehouse, Inc.!

Looking forward to hearing from you,
Jay Dohrmann
Recruiting/Personnel/Safety
Ph. 800-992-4451 x2
jdohrmann@machlink.com

*net of fuel (surcharge)

DRIVERS APPLICATION FOR EMPLOYMENT OR LEASE

NEWCOMB WAREHOUSE, INC.
P.O. Box 673
3606 Grandview Avenue
Muscatine, IA 52761
Ph.: (563) 263-7661 Toll Free (800) 992-4451
Fax: (563) 263-2123
(ANSWER ALL QUESTIONS, DO NOT LEAVE ANY BLANKS!)
In compliance with Federal and State equal employment opportunity laws, qualified applicants are considered for all positions without regard to race, color, religion, sex, national origin, age, marital status, veteran status, non-job related disability, or any other protected group status.
Date of Application:

MonthDayYear
OTR DRIVER
Position(s) applied for
Name
Social Security No
IN CASE OF EMERGENCY, CONTACT:
PHONE
List your address of residency for the past 3 years.
Current Address
Phone
How long?
Previous Address
Do you have the legal right to work in the United States?
Date of Birth

MonthDayYear
(Required for Commercial Drivers)
Can you provide proof of age?
Have you worked for this company before?
Where?
Dates:
Rate of Pay
Position
Reason for Leaving
Are you now employed?
If not, how long since leaving last employment?
Who referred you?
Rate of pay expected
Is there any reason you might be unable to perform the functions of the job for which you have applied [as described in the posted job description]?
If yes, please explain of you’d like:
EMPLOYMENT & LEASE HISTORY

All drivers and or owner/operators must list your previous employment or lease for the past 3 years. If you have been driving for more than 3 years you must list employment for up to additional years….For vehicles with GVWR of 26,001 lbs or more, vehicles designed to haul 15 or more passengers and/or vehicles transporting hazardous materials in quantities requiring placards.

**FILL IN ALL INFORMATION, ATTACHING SEPARATE SHEET(S) IF NECESSARY FOR ADDITIONAL EMPLOYERS **
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** MAKE YOU SURE YOU COMPLETED ALL INFORMATION **

HireRight
DAC Trucking
TRUCKING INDUSTRY: DOT DIA Disclosure and Authorization
Send to Fax# (800) 257-8069
HireRight Customer:
Company Name:
Fax #:
Company Contact Name:
HireRight Account Code:
PART 1 - DISCLOSURE AND AUTHORIZATION FOR RELEASE OF INFORMATION FOR EMPLOYMENT PURPOSES - 49 CFR PART 391.23, DOT DRUG AND ALCOHOL TESTING

In accordance with DOT Regulation 49 CFR Part 391.23, I hereby authorize release of my DOT-regulated drug and alcohol testing records by the DOT-regulated employer(s) listed below to HireRight for the purpose of HireRight transmitting such records to the HireRight customer listed above. I understand that information/documents released pursuant to this part I is limited to the following DOT-regulated testing items, including pre-employment testing results, occurring during the previous three (3) years: (i) alcohol tests with a result of 0.04 or higher; (ii) verified positive drug tests; (iii) refusals to be tested (including adulterated and/ or substituted tests); (iv) other violations of DOT drug and alcohol testing regulations (i.e., violations of 49 CFR 382 Subpart B); (v) information obtained from previous employers of a drug and alcohol rule violation; and (vi) any documentation of completion of the return-to-duty process following a rule violation.

If any company listed below furnishes HireRight with information concerning items (i) through (vi) above, I also authorize such company to furnish the following information to HireRight, if applicable: (i) dates of my negative drug and/or alcohol tests and/or tests with results below 0.04 during the previous three (3) years; and (ii) the name and phone number of any substance abuse professional who evaluated me during the previous three (3) years.
List all DOT-regulated employers you have applied with and/or worked for in a safety-sensitive function during the previous three (3) years. If necessary, attach additional pages, including the date, your name, social security number and signature.

	Previous DOT-Regulated Employer	City	State	Phone Number
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By signing below, I certify that: (i) all information provided herein is complete and accurate; (ii) I have read and fully understand this Part I disclosure and authorization for release as well as the attached FMCSA Notification of Driver Rights and any applicable state law notices; (iii) prior to signing I was given an opportunity to ask questions and to have those questions answered to my satisfaction; (iv) I execute this authorization voluntarily and with the knowledge that the information obtained pursuant to this authorization could affect my eligibility for employment, promotion, retention or other lawful purpose; (v) I understand I may review this document with legal counsel prior to signing; and (vi) facsimile or photographic copies of this authorization are as valid as an original.
Print Applicant Name:
Social Security #:
Applicant Signature:*
Date:

MonthDayYear
DOT Drug/Alcohol Disclosure Authorization Trucking Industry - Employment Purpose

NEWCOMB WAREHOUSE, INC.
3606 Grandview Avenue
Muscatine, IA 52761
Ph.: (563) 263-7661 Fax: (563) 263-2123
PREVIOUS PRE-EMPLOYMENT APPLICANT ALCOHOL AND DRUG TEST STATEMENT
Sec. 40.25(j) As the employer, you must ask the applicant employee whether he or she has tested positive, or refused to test, on any pre-employment drug or alcohol test administered by an employer to which the employee applicant applied for, but did not obtain, safety-sensitive transportation work covered by DOT agency drug and alcohol testing rules during the past three years. If the employee applicant admits that he or she had a positive test or refusal to test, you must not use the employee applicant to perform safety-sensitive functions for you, until the employee applicant documents successful completion of the return-to-duty process. [SEE Sec. 40.25(b)(5) and (e)]

Company Name: NEWCOMB WAREHOUSE, INC.

Street: 3606 Grandview Ave.

City/State/Zip:Muscatine, IA 52761
Prospective Employee Name:
Social Security #:
The prospective employee is required by Sec. 40.25(j) to respond to the following questions.
1) Have you tested positive, or refused to test, on any pre-employment drug or alcohol test administered by an employer to which you applied for, but did not obtain, safety sensitive transportation work covered by DOT agency drug and alcohol testing rules during the past three years?Check one:

YesNo
2) If you answered yes, can you provide/obtain proof that you've successfully completed the DOT return to duty requirements?Check one:

YesNo
Prospective Employee Signature:*
Date:

MonthDayYear
Witnessed by:
Date:

MonthDayYear

NEWCOMB WAREHOUSE, INC.
3606 Grandview Avenue
Muscatine, IA 52761
Ph.: (563) 263-7661 Fax: (563) 263-2123
REQUEST FOR CHECK OF DRIVING RECORD
I hereby authorize you to release the following to NEWCOMB WAREHOUSE, INC. P.O. Box 673 3606 Grandview Ave. Muscatine, IA 52761 for purposes of investigation as required by Section 391.23 of the Federal Motor Carrier Safety Regulations. You are released from any and all liability which may result from furnishing such information.
Applicant's Signature:*
Date:

MonthDayYear
1) In accordance with the provisions of Section 604 and Section 607 of the Fair Credit Reporting Act, Public Law No. 91-508, I hereby certify that the information requested below will be used for a "permissible purpose" as defined in the Act, and that the information received will be used for no other purpose.

2) I further certify that if the applicant named below is denied employment based upon the information received, i will identify the source of the report in accordance with Section 615(a) of the Fair Credit Reporting Act.
Applicant's Signature:*
Date:

MonthDayYear
TO: Dept. of Driver Services
Gentlemen:
Name of Applicant:
Address:
Former Address:
Date of Birth:

MonthDayYear
SS Number:
Drivers License Number
REQUESTED BY
Signature:*
Title:
Safety Director:

THE BELOW DISCLOSURE AND AUTHORIZATION LANGUAGE IS FOR MANDATORY USE BY ALL ACCOUNT HOLDERS
IMPORTANT DISCLOSURE REGARDING BACKGROUND REPORTS FROM THE PSP Online Service
In connection with your application for employment with Newcomb Warehouse, Inc. (“Prospective Employer”), Prospective Employer, its employees, agents or contractors may obtain one or more reports regarding your driving, and safety inspection history from the Federal Motor Carrier Safety Administration (FMCSA).

When the application for employment is submitted in person, if the Prospective Employer uses any information it obtains from FMCSA in a decision to not hire you or to make any other adverse employment decision regarding you, the Prospective Employer will provide you with a copy of the report upon which its decision was based and a written summary of your rights under the Fair Credit Reporting Act before taking any final adverse action. If any final adverse action is taken against you based upon your driving history or safety report, the Prospective Employer will notify you that the action has been taken and that the action was based in part or in whole on this report.

When the application for employment is submitted by mail, telephone, computer, or other similar means, if the Prospective Employer uses any information it obtains from FMCSA in a decision to not hire you or to make any other adverse employment decision regarding you, the Prospective Employer must provide you within three business days of taking adverse action oral, written or electronic notification; that adverse action has been taken based in whole or in part on information obtained from FMCSA; the name, address, and the toll free telephone number of FMCSA; that the FMCSA did not make the decision to take the adverse action and is unable to provide you the specific reasons why the adverse action was taken; and that you may, upon providing proper identification, request a free copy of the report and may dispute with the FMCSA the accuracy or completeness of any information or report. If you request a copy of a driver record from the Prospective Employer who procured the report, then, within 3 business days of receiving your request, together with proper identification, the Prospective Employer must send or provide to you a copy of your report and a summary of your rights under the Fair Credit Reporting Act.

Neither the Prospective Employer nor the FMCSA contractor supplying the crash and safety information has the capability to correct any safety data that appears to be incorrect. You may challenge the accuracy of the data by submitting a request to https://dataqs.fmcsa.dot.gov. If you challenge crash or inspection information reported by a State, FMCSA cannot change or correct this data. Your request will be forwarded by the DataQs system to the appropriate State for adjudication.

Any crash or inspection in which you were involved will display on your PSP report. Since the PSP report does not report, or assign, or imply fault, it will include all Commercial Motor Vehicle (CMV) crashes where you were a driver or co-driver and where those crashes were reported to FMCSA, regardless of fault. Similarly, all inspections, with or without violations, appear on the PSP report. State citations associated with Federal Motor Carrier Safety Regulations (FMCSR) violations that have been adjudicated by a court of law will also appear, and remain, on a PSP report.

The Prospective Employer cannot obtain background reports from FMCSA without your authorization.

AUTHORIZATION

If you agree that the Prospective Employer may obtain such background reports, please read the following and sign below:

I authorize Newcomb Warehouse, Inc. (“Prospective Employer'') to access the FMCSA Pre-Employment Screening Program (PSP) systein to seek inforınation regarding my commercial driving safety record and information regarding my safety inspection history. I understand that I am authorizing the release of safety performance information including crash data from the previous five (5) years and inspection history from the previous three (3) years. I understand and acknowledge that this release of information may assist the Prospective Employer to make a determination regarding my suitability as an employee.

I further understand that neither the Prospective Employer nor the FMCSA contractor supplying the crash and safety information has the capability to correct any safety data that appears to be incorrect. I understand I may challenge the accuracy of the data by submitting a request to https://dataqs.fmcsa.dot.gov. If I challenge crash or inspection information reported by a State, FMCSA cannot change or correct this data. I understand my request will be forwarded by the DataQs system to the appropriate State for adjudication.

I understand that any crash or inspection in which I was involved will display on my PSP report. Since the PSP report does not report, or assign, or imply fault, I acknowledge it will include all CMV crashes where I was a driver or co-driver and where those crashes were reported to FMCSA, regardless of fault. Similarly, I understand all inspections, with or without violations, will appear on my PSP report, and State citations associated with FMCSR violations that have been adjudicated by a court of law will also appear, and remain, on my PSP report. I have read the above Disclosure Regarding Background Reports provided to me by Prospective Employer and I understand that if I sign this Disclosure and Authorization, Prospective Employer may obtain a report of my crash and inspection history. I hereby authorize Prospective Employer and its employees, authorized agents, and/or affiliates to obtain the information authorized above.
Date:

MonthDayYear
Signature:*
Name (Please Print):
NOTICE: This form is made available to monthly account holders by NIC on behalf of the U.S. Department of Transportation, Federal Motor Carrier Safety Administration (FMCSA). Account holders are required by federal law to obtain an Applicant's written or electronic consent prior to accessing the Applicant's PSP report. Further, account holders are required by FMCSA to use the language contained in this Disclosure and Authorization form to obtain an Applicant's consent. The language must be used in whole, exactly as provided. Further, the language on this form must exist as one stand-alone document. The language may NOT be included with other consent forms or any other language.

LAST UPDATED 12/22/2015
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	CLASS OF EQUIPMENT	TYPE OF EQUIP. (VAN, REEFER, FLAT, ETC.)	DATES FROM	DATES TO	APPROX. TOTAL NUMBER OF MILES
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