DOT SAFETY AUDIT

• Document No.

• Legal Name

• Trade Name

• USDOT #

• Conducted on

  Date
• Address
  Address

• Assessor

COMPANY OPERATION

• (Mark all that apply)

  Select Interstate Carrier Interstate Hazmat Carrier Intrastate Non-Hazmat Carrier Intrastate Hazmat Carrier Interstate Hazmat Shipper Intrastate Hazmat Shipper

  • Interstate Carrier
  • Interstate Hazmat Carrier
  • Intrastate Non-Hazmat Carrier
  • Intrastate Hazmat Carrier
  • Interstate Hazmat Shipper
  • Intrastate Hazmat Shipper

OPERATION CLASSIFICATION

• (Mark all that apply)

  Select Authorized For-Hire Exempt For-Hire Private Property Private Passenger (Business) Private Passenger (Non-Business) Migrant U.S. Mail Federal Government State Government Local Government Indian Tribe Other

  • Authorized For-Hire
  • Exempt For-Hire
  • Private Property
  • Private Passenger (Business)
  • Private Passenger (Non-Business)
  • Migrant
  • U.S. Mail
  • Federal Government
  • State Government
  • Local Government
  • Indian Tribe
  • Other

• Other

HAZARDOUS MATERIALS

• Do you transport hazardous materials?

  Yes

  No

• List all Hazardous Materials Transported

  Select Div 1.1 Div 1.2 Div 1.3 Div 1.4 Div 1.5 Div 1.6 Div 2.1 Flam. Gas Div 2.1 LPG Div 2.1 (Methane) Div 2.2 Div 2.2 D (Ammonia) Div 2.3 A Div 2.3 B Div 2.3 C Div 2.3 D Class 3 Class 3 A Class 3 B Combustible Liquid Div 4.1 Div 4.2 Div 4.3 Div 5.1 Div 5.2 Div 6.2 Div 6.1 A Div 6.1 B Div 6.1 Poison Div 6.1 Solid Class 7 HRCQ Class 8 Class 8 A Class 8 B Class 9 Elevated Temperature Materials Infectious Waste Marine Pollutants Hazardous Substance (RQ) Other Regulated Material (ORM)

  • Div 1.1
  • Div 1.2
  • Div 1.3
  • Div 1.4
  • Div 1.5
  • Div 1.6
  • Div 2.1 Flam. Gas
  • Div 2.1 LPG
  • Div 2.1 (Methane)
  • Div 2.2
  • Div 2.2 D (Ammonia)
  • Div 2.3 A
  • Div 2.3 B
  • Div 2.3 C
  • Div 2.3 D
  • Class 3
  • Class 3 A
  • Class 3 B
  • Combustible Liquid
  • Div 4.1
  • Div 4.2
  • Div 4.3
  • Div 5.1
  • Div 5.2
  • Div 6.2
  • Div 6.1 A
  • Div 6.1 B
  • Div 6.1 Poison
  • Div 6.1 Solid
  • Class 7
  • HRCQ
  • Class 8
  • Class 8 A
  • Class 8 B
  • Class 9
  • Elevated Temperature Materials
  • Infectious Waste
  • Marine Pollutants
  • Hazardous Substance (RQ)
  • Other Regulated Material (ORM)

• Do you transport placardable quantities of HM?

  Yes

  No

• Is an HM permit required?

  Yes

  No

• Enter HM permit number here

COMMODITIES

• List all commodities transported

  Select General Freight Household Goods Metal: Sheets, Coils, Rolls Motor Vehicles Drive Away/Towaway Logs, Poles, Beams, Lumber Building Materials Mobile Homes Machinery, Large Objects Fresh Produce Liquids / Gases Intermodal Cont Passengers Oil Field Equipment Livestock Grain, Feed, Hay Coal / Coke Meat Garbage, Refuse, Trash U.S. Mail Chemicals Commodities Dry Bulk Refrigerated Foods Beverages Paper Product Utility Farm Supplies Construction Water Well Other

  • General Freight
  • Household Goods
  • Metal: Sheets, Coils, Rolls
  • Motor Vehicles
  • Drive Away/Towaway
  • Logs, Poles, Beams, Lumber
  • Building Materials
  • Mobile Homes
  • Machinery, Large Objects
  • Fresh Produce
  • Liquids / Gases
  • Intermodal Cont
  • Passengers
  • Oil Field Equipment
  • Livestock
  • Grain, Feed, Hay
  • Coal / Coke
  • Meat
  • Garbage, Refuse, Trash
  • U.S. Mail
  • Chemicals
  • Commodities Dry Bulk
  • Refrigerated Foods
  • Beverages
  • Paper Product
  • Utility
  • Farm Supplies
  • Construction
  • Water Well
  • Other

• Other

DRIVER INFORMATION

• Interstate Drivers (Previous 365 Days)

• Intrastate Drivers (Previous 365 Days)

• Total CDL Drivers

• Total Non-CDL Drivers

STRAIGHT TRUCKS

• Do you operate any straight trucks?

  Yes

  No

• Do you own any straight trucks?

  Yes

  No

• Total

• Do you term lease any straight trucks?

  Yes

  No

• Total

• Do you have any trip leased straight trucks?

  Yes

  No

• Total

TRUCK TRACTORS

• Do you operate any truck tractors?

  Yes

  No

• Do you own any truck tractors?

  Yes

  No

• Total

• Do you term lease any truck tractors?

  Yes

  No

• Total

• Do you trip lease any truck tractors?

  Yes

  No

• Total

TRAILERS

• Do you utilize any trailers?

  Yes

  No

• Do you own any trailers?

  Yes

  No

• Total

• Do you term lease any trailers?

  Yes

  No

• Total

• Do you trip lease any trailers?

  Yes

  No

• Total

HAZMAT CARGO TANK TRUCKS

• Do you operate any HM cargo tank trucks?

  Yes

  No

• Do you own any HM cargo tank trucks?

  Yes

  No

• Total

• Do you term lease any HM cargo tank trucks?

  Yes

  No

• Total

• Do you trip lease any HM cargo tank trucks?

  Yes

  No

• Total

HAZMAT CARGO TANK TRAILERS

• Do you utilize any cargo tank trailers?

  Yes

  No

• Do you own any HM cargo tank trailers?

  Yes

  No

• Total

• Do you term lease any HM cargo tank trailers?

  Yes

  No

• Total

• Do you trip lease any HM cargo tank trailers?

  Yes

  No

• Total

MOTORCOACH

• Do you operate any motorcoaches?

  Yes

  No

• Do you own any motorcoaches?

  Yes

  No

• Total

• Do you term lease any motorcoaches?

  Yes

  No

• Total

• Do you trip lease any motorcoaches?

  Yes

  No

• Total

SCHOOL BUS

• Do you operate any school buses?

  Yes

  No

• Do you own any school buses?

  Yes

  No

• Total

• Do you term lease any buses?

  Yes

  No

• Total

• Do you trip lease any buses?

  Yes

  No

• Total

MINI-BUS

• Do you operate any mini-buses?

  Yes

  No

• Do you own any mini-buses?

  Yes

  No

• Total

• Do you term lease any mini-buses?

  Yes

  No

• Total

• Do you trip lease any mini-buses?

  Yes

  No

• Total

PASSENGER VAN

• Do you operate any passenger vans?

  Yes

  No

• Do you own any passenger vans?

  Yes

  No

• Total

• Do you term lease any passenger vans?

  Yes

  No

• Total

• Do you trip lease any passenger vans?

  Yes

  No

• Total

LIMOUSINE

• Do you operate any limousines?

  Yes

  No

• Do you own any limousines?

  Yes

  No

• Total

• Do you term lease any limousines?

  Yes

  No

• Total

• Do you trip lease any limousines?

  Yes

  No

• Total

TOTAL MILES DRIVEN FOR PREVIOUS YEAR

• Mileage

TOTAL INSPECTIONS (Roadside / Terminal)

• Have you had any roadside or terminal inspections within the previous 365 days?

  Yes

  No

• Total

• Were any inspections out-of-service?

  Yes

  No

  N/A

• Total

RECORDABLE ACCIDENTS (Fatalities, Injuries Requiring Immediate Medical Treatment, Towed Vehicles)

• Have you had any recordable accidents in the previous 3 years?

  Yes

  No

• List all recordable accidents.

LOCATION OF REVIEW

• Where was the review conducted?

  Select Principal Place of Business Terminal Location EA Office Other

  • Principal Place of Business
  • Terminal Location
  • EA Office
  • Other

• Other Location

IFTA / IRP

• Have you filed for IFTA / IRP registration?

  Yes

  No

  N/A

• Date Completed

UCR

• Have you filed your UCR registration?

  Yes

  No

  N/A

• Date Completed

MCS-150 UPDATE / CHANGES

• Have you completed your MCS-150 application / update / changes?

  Yes

  No

  N/A

• Date Completed

INTERSTATE FOR-HIRE AUTHORITY (if applicable)

• Have you applied for your interstate for-hire authority?

  Yes

  No

  N/A

• Enter Interstate (MC) Authority information

INTRASTATE FOR-HIRE AUTHORITY (If applicable)

• Have you applied for your intrastate for-hire authority?

  Yes

  No

  N/A

• Enter Intrastate Authority information (if applicable)

GENERAL

• General #1 Section # 387.7(a) - Acute<br>Does the carrier have the required minimum level of financial responsibility in effect (property carrier)?

  Yes

  No

  N/A

• General # 2 Section # 387.7(d) - Critical<br>Does the carrier have required proof of financial responsibility (property carrier)?

  Yes

  No

  N/A

• General # 3 Section # 387.31(a) - Acute<br>Does the carrier have the required minimum level of financial responsibility in effect (passenger carrier)?

  Yes

  No

  N/A

• General # 4 Section # 387.31(d) - Critical<br>Does the carrier have the required proof of financial responsibility (passenger carrier)?

  Yes

  No

  N/A

• General # 5 Section 13901 (392.9a(a)(1))<br>Is the motor carrier authorized to conduct interstate operations in the United States?

  Yes

  No

  N/A

• General # 6 Section # 390.15(b)(1)<br>Can the carrier provide a complete accident register of recordable accidents?

  Yes

  No

  N/A

• General # 7 Section # 390.15(b)(2) - Critical<br>Does the carrier have copies of all accident reports required by States or other government entities or insurers?

  Yes

  No

  N/A

• General # 8 Section # 390.3(e)<br>Is the carrier knowledgeable of the FMCSRs/HMRs?

  Yes

  No

  N/A

• General # 9 Section # 390.21<br>Does the carrier know the commercial motor vehicles marking requirements?

  Yes

  No

  N/A

DRIVER

• Driver # 1 Section # 391.51(a) - Critical<br>Does the carrier maintain driver qualification files?

  Yes

  No

  N/A

• Driver # 2 Section # 391.11(b)(4) - Acute<br>Is the carrier using physically qualified drivers?

  Yes

  No

  N/A

• Driver # 3 Section # 391.45(a), 391.45(b) - Critical<br>Is the carrier using a driver without a medical certificate or with an expired medical certificate?

  Yes

  No

  N/A

• Driver # 4 Section # 391.15(a) - Acute<br>Is the carrier using any disqualified drivers?

  Yes

  No

  N/A

• Driver # 5 Section # 391.51(b)(2) - Critical<br>Does the carrier maintain driving inquiry data in driver qualification files?

  Yes

  No

  N/A

COMMERCIAL DRIVERS LICENSE (CDL)

• Are any drivers required to have a CDL?

  Yes

  No

• Driver # 6 Section # 382.115(a), 382.115(b) - Acute<br>Has the carrier implemented an alcohol and/or controlled substances testing program?

  Yes

  No

• Driver # 7 Section # 382.213(b) - Acute<br>Has the carrier used drivers who have used controlled substances?

  Yes

  No

• Driver # 8 Section # 382.215 - Acute<br>Has the carrier used a driver who has tested positive for a controlled substance?

  Yes

  No

• Driver # 9 Section # 382.301 - Acute<br>Has the carrier used a driver known to have an alcohol concentration of 0.04 or greater?

  Yes

  No

• Driver # 10 Section # 382.505(a) - Acute<br>Has the carrier used a driver found to have an alcohol concentration of 0.02 or greater but less than 0.04 within 24 hours of being tested?

  Yes

  No

• Driver # 11 Section # 382.301(a) - Critical<br>Has the carrier ensured that drivers have undergone testing for controlled substances prior to performing a safety sensitive function?

  Yes

  No

• Driver # 12 Section # 382.303(a) - Critical<br>Has the carrier conducted post accident testing on driver for alcohol?

  Yes

  No

  N/A

• Driver # 13 Section # 382.303(b) - Critical<br>Has the carrier conducted post accident testing on drivers for controlled substances?

  Yes

  No

  N/A

• Driver # 14 Section 382.305 - Acute<br>Has the carrier implemented a random testing program?

  Yes

  No

• Driver # 15 Section 382.305(b)(1) - Critical<br>Has the carrier conducted random alcohol testing at an annual rate of not less than the applicable annual rate or prorated rate of the average number of driver positions?

  Yes

  No

• Driver # 16 Section # 382.305(b)(2) - Critical<br>Has the carrier conducted controlled substance testing at the applicable prorated rate of not less than the applicable annual rate of the average number of driver positions?

  Yes

  No

• Driver # 17 Section # 40.305(a)<br>Has the carrier conducted the required return-to-duty tests on employees returning to safety-sensitive functions?

  Yes

  No

  N/A

• Driver # 18 Section # 40.309(a)<br>Is the carrier conducting follow-up testing as directed by the Substance Abuse Professional?

  Yes

  No

  N/A

• Driver # 19 Section # 382.211 - Acute<br>Has the carrier used a driver who has refused to submit to an alcohol or controlled substances test required under Part 382?

  Yes

  No

• Driver # 20 Section # 382.503 - Critical<br>Has the carrier used a Substance Abuse Professional as required by 49 CFR Part 40 Subpart O?

  Yes

  No

  N/A

• Driver # 21 Section # 383.23(a) - Critical<br>Has a driver operated a commercial motor vehicle without a current operating license, or a license, which hasn't been properly classed and endorsed?

  Yes

  No

• Driver # 22 Section # 383.37(a) - Acute<br>Has the motor carrier knowingly allowed its drivers whose CDLs have been suspended, revoked or canceled by a state, have lost the right to operate a CMV in a state, or have been disqualified from operating a CMV to operate a commercial motor vehicle?

  Yes

  No

• Driver # 23 Section # 383.51(a) - Acute<br>Has the motor carrier knowingly allowed, required, permitted, or authorized a driver to drive who is disqualified to drive a commercial motor vehicle?

  Yes

  No

OPERATIONS

• Do any drivers utilize a time sheet to record hours of service?

  Yes

  No

• Operations # 1 Section # 395.1(e)(1), 395.1(e)(2)<br>Does the carrier have a system for recording hours of duty status on 100/150 air-mile radius drivers, and are they properly utilizing the 100/150 air-mile radius exemption?

  Yes

  No

• Operations # 2 Section # 395.8(a) - Critical<br>Does the carrier require drivers to make a record of duty status?

  Yes

  No

  N/A

• Operations # 3 Section # 395.8(i) - Critical<br>Does the carrier require drivers to submit records of duty status within 13 days?

  Yes

  No

• Operations # 4 Section # 395.8(k)(1) - Critical<br>Can the carrier produce records of duty status and supporting documents for selected drivers?

  Yes

  No

• Operations # 5 Section # 395.3(a)(1) - Critical<br>Has the carrier allowed driver(s) to exceed the 11-hour rule? (Property)

  Yes

  No

• Operations # 6 Section # 395.3(a)(2) - Critical<br>Has the carrier allowed driver(s) to exceed the 14-hour rule? (Property)

  Yes

  No

• Operations # 7 Section # 395.3(b)(1) - Critical<br>Has the carrier allowed driver(s) to drive after having been on duty more than 60 hours in 7 consecutive days? (Property)

  Yes

  No

  N/A

• Operations # 8 Section # 395.3(b)(2) - Critical<br>Has the carrier allowed driver(s) to drive after having been on duty more than 70 hours in 8 consecutive days? (Property)

  Yes

  No

  N/A

• Operations # 9 Section # 395.5(a)(1) - Critical<br>Has the carrier allowed driver(s) to exceed the 10-hour rule? (Passenger)

  Yes

  No

  N/A

• Operations # 10 Section # 395.5(a)(2) - Critical<br>Has the carrier allowed driver(s) to exceed the 15-hour rule? (Passenger)

  Yes

  No

  N/A

• Operations # 11 Section # 395.5(b)(1) - Critical<br>Has the carrier allowed driver(s) to driver after having been on duty more than 60 hours in 7 consecutive days? (Passenger)

  Yes

  No

  N/A

• Operations # 12 Section # 395.5(b)(2) - Critical<br>Has the carrier allowed driver(s) to driver after having been on duty more than 70 hours in 8 consecutive days? (Passenger)

  Yes

  No

  N/A

• Operations # 13 Section # 395.8(e) - Critical<br>Does available evidence indicate a selected driver has prepared a false record of duty status?

  Yes

  No

• Operations # 14 Section # 392.2 - Critical<br>Does the motor carrier ensure that drivers operate commercial motor vehicles in accordance with the laws, ordinances, and regulations of the jurisdictions in which they are operating?

  Yes

  No

• Operation # 15 Section # 392.9(a)(1) - Critical<br>Does the carrier ensure that drivers are not permitted to drive a vehicle without the cargo properly distributed and adequately secured?

  Yes

  No

• Operations # 16 Section # 392.4(b) - Acute<br>Have any drivers operated a commercial motor vehicle while under the influence of, or in possession of, narcotic drugs, amphetamines, or any other substances capable of rendering the drivers incapable of safely operating motor vehicles?

  Yes

  No

• Operations # 17 Section # 392.5(b)(1) - Acute<br>Have any drivers operated a commercial motor vehicle while under the influence of, or in possession of, intoxicating beverages?

  Yes

  No

• Operations # 18 Section # 392.5(b)(2) - Acute<br>Have any drivers operated a commercial motor vehicle within 4 hours of having consumed intoxicating beverages?

  Yes

  No

MAINTENANCE

• Maintenance # 1 Section # 396.3(b) - Critical<br>Can the carrier produce maintenance files for requested vehicle(s)?

  Yes

  No

  N/A

• Maintenance # 2 Section # 396.17(a) - Critical<br>Can the carrier produce evidence of periodic (annual) inspections for selected vehicles?

  Yes

  No

  N/A

• Maintenance # 3 Section # 396.11(a) - Critical<br>Does the motor carrier require drivers to complete vehicle inspection reports daily?

  Yes

  No

  N/A

• Maintenance # 4 Section # 396.11(c) - Acute<br>Does the carrier ensure that out-of-service defects listed by the driver in the driver vehicle inspection reports are corrected before the vehicle is operated again?

  Yes

  No

  N/A

• Maintenance # 5 Section # 396.9(c)(2) - Acute<br>Does the carrier ensure vehicles that have been declared "out-of-service" do not operate before repairs have been made?

  Yes

  No

  N/A

• Maintenance # 6 Section 396.19<br>Is the carrier using qualified inspections (mechanic) and maintaining evidence of the inspector's qualifications?

  Yes

  No

  N/A

• Maintenance # 7 Section # 396.3<br>Can the carrier explain its systematic, periodic maintenance program?

  Yes

  No

  N/A

HAZARDOUS MATERIALS

• Does the carrier transport any amount of hazardous materials?

  Yes

  No

• Hazardous Materials # 1 Section # 107.608(a)<br>Is the carrier registered with the Pipeline and Hazardous Materials Safety Administration, and to they have copies of all their registrations for the previous 3 years?

  Yes

  No

  N/A

• Hazardous Materials # 2 Section # 171.15 - Critical<br>Does the carrier promptly report hazardous materials incidents requiring immediate telephone notice to the appropriate authorities?

  Yes

  No

  N/A

• Hazardous Materials # 3 Section # 171.16 - Critical<br>Does the carrier file hazardous materials incident reports when required?

  Yes

  No

  N/A

• Hazardous Materials # 4 Section # 177.800(c) - Critical<br>Does the carrier provide HM training for its drivers?

  Yes

  No

  N/A

• Hazardous Materials # 5 Section # 172.704(a)<br>Do the HM training materials cover the minimum required elements?

  Yes

  No

  N/A

• Hazardous Materials # 6 Section # 177.817(a) - Critical<br>Are the shipping papers used by the carrier properly prepared?

  Yes

  No

  N/A

• Hazardous Materials # 7 Section # 177.817(e) - Critical<br>Does the carrier maintain proper accessibility for shipping papers?

  Yes

  No

  N/A

• Hazardous Materials # 8 Section # 177.841(e) - Acute<br>Does the carrier transport packages bearing a poison label in the same vehicle with any foodstuff or feed for humans or animals?

  Yes

  No

  N/A

• Hazardous Materials # 9 Section # 177.848<br>Is the motor carrier aware that some hazardous materials may not be transported in the same vehicle with other hazardous materials?

  Yes

  No

  N/A

• Hazardous Materials # 10 Section # 180.407(a) - Critical<br>Has the carrier transported a shipment of HM in a cargo tank that has not been inspected or tested in accordance with 180.407?

  Yes

  No

  N/A

• Hazardous Materials # 11 Section # 180.407(c) - Critical<br>Are all of the cargo tanks used for the transportation of hazardous materials periodically inspected and tested in accordance with 180.407?

  Yes

  No

  N/A

• Hazardous Materials # 12 Section # 180.415 - Critical<br>Are cargo tanks that pass inspections or tests required by 180.407 marked?

  Yes

  No

  N/A

• Hazardous Materials # 13 Section # 180.417(a)(1) - Critical<br>Has the carrier retained all of the manufacturer's data report certificates and related papers, as required?

  Yes

  No

  N/A

• Hazardous Materials # 14 Section # 397.5(a) - Acute<br>Does the carrier ensure that vehicles containing Division 1.1, 1.2, or 1.3 (explosive) material is attended at all times?

  Yes

  No

  N/A

• Hazardous Materials # 15 Section # 397.7(a)(1) - Critical<br>Has the motor carrier parked a vehicle containing Division 1.1, 1.2, or 1.3 materials within 5 feet of a traveled portion of a highway or street?

  Yes

  No

  N/A

• Hazardous Materials # 16 Section # 397.7(b) - Critical<br>Has the motor carrier parked a vehicle containing HM other than Division 1.1, 1.2, or 1.3 materials within 5 feet of a traveled portion of a highway or street?

  Yes

  No

  N/A

• Hazardous Materials # 17 Section # 397.13(a) - Critical<br>Has the carrier permitted anyone to smoke when within 25 feet of a vehicle containing Class 1 materials, Class 5 materials, or flammable materials classified in Division 2.1, Class 3, Divisions 4.1, and 4.2?

  Yes

  No

  N/A

• Hazardous Materials # 18 Section # 397.19(a) - Critical<br>Has the carrier furnished all drivers transporting Division 1.1, 1.2, or 1.3 (explosive) material a copy of the rules of Part 397 and/or emergency response instructions?

  Yes

  No

  N/A

• Hazardous Materials # 19 Section # 397.67(d) - Critical<br>Does the carrier have a system to ensure all drivers transporting Class 7 (radioactive) material, Division 1.1, 1.2, or 1.3 explosives, or a poison inhalation hazard Zone A or B materials have a written route plan?

  Yes

  No

  N/A

OTHER

• Does the carrier transport household good or operate any Over The Road Buses (OTBR)

  Yes

  No

• Other # 1 Section # 375.211<br>Does the carrier participate in an Arbitration Program?

  Yes

  No

  N/A

• Other # 2 Section 13702.0<br>Does the carrier assess shipper freight charges based upon published tariffs?

  Yes

  No

  N/A

• Other # 3 Section # 375.401(c)<br>Does the carrier provide reasonably accurate estimates of moving charges?

  Yes

  No

  N/A

• Other #4 Section # 375.407(a), 375.703(b)<br>Has the carrier avoided "hostage freight" or other predatory practices?

  Yes

  No

  N/A

• Other # 5 Section # 387.301(a), 387.301(b)<br>Does the HHG carrier have sufficient levels of public liability and cargo insurance?

  Yes

  No

  N/A

• Other # 6 Section # 375.215<br>Does the carrier have a published tariff and is the motor carrier changing the applicable rate (375.215)?

  Yes

  No

  N/A

• Other # 7 Section # 375.213<br>Can the motor carrier identify five documents required to be given to a prospective individual shipper prior to executing an order for service?

  Yes

  No

  N/A

• Other # 8 Section # 49 CFR 37 subpart H<br>Does the carrier have the means to provide accessible over-the-road bus (OTRB) service on a 48-hour advance notice basis by its owned or leased OTRBs?

  Yes

  No

  N/A

• Other # 9 Section # 49 CFR 37 subpart H<br>If the carrier does not have the means then does the carrier have an arrangement with another carrier that operates accessible OTRBs?

  Yes

  No

  N/A

RECEIPT

• This audit is used to determine your compliance with the Federal Motor Carrier Safety Regulations (FMCSRs). Any violations discovered may be utilized to help determine the areas of concern that need addressing.
  
  Your signature for receipt of this report acknowledges your understanding that if any violations are discovered they will be corrected as earliest as possible. You also understand that by failing to correct any violations discovered, you will be held liable for any violations that may be discovered during a compliance review from FMCSA or your States Enforcement Agency.
  
  You also agree not to hold Employer Advantage and/or its representative liable for any violations discovered during a safety audit or compliance review conducted by any investigator or enforcement officer.
  
  Refusing to sign this report does not in any way release you from any liability.

• Assessor Signature

  Sign

• Company Official

  Sign