CDL Employment Application

In compliance with the 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.  I authorize you to make such investigations and inquiries of my personal, employment, financial or medical history and other related matters as may be necessary in arriving at an employment decision.  (Generally, inquiries regarding medical history will be made only if and after a conditional offer of employment has been extended.)  I hereby release employers, schools, healthcare providers and other persons from all liability in responding to inquiries and releasing information 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. If necessary for employment, I may be required to: supply my birth certificate or other proof of authorization to work in the U.S., have a physical examination and/or drug test, or to sign a conflict of interest agreement and abide by its terms.   I understand that the 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 that 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 the corrected information to the prospective employer; and Have a rebuttal statement attached to the alleged erroneous information, If the previous employer(s) and I cannot agree on the accuracy of the information. I understand and agree to the information shown above.

In connection with your application for employment with this company (“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.

If you agree that the Prospective Employer may obtain such background reports, please read the following and sign below: I authorize this company (“Prospective Employer”) to access the FMCSA Pre-Employment Screening Program (PSP) system to seek information 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.

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. NOTICE: The prospective employment concept referenced in this form contemplates the definition of “employee” contained at 49 C.F.R. 383.5.

The “Company” may request, for lawful employment purposes, background information about you from MVRcheck.com (Consumer Reporting Agency) in connection with your employment or application for employment (including independent contractor assignments, as applicable). The consumer report may include Driving History (Motor Vehicle Records), CDL Records, FMCSA PSP Records, Drug & Alcohol Tests, Previous Employment Verifications, County Court Records, and Identity Verification. Consumer reports and/or investigative consumer reports are to be generated for employment, promotion, reassignment, retention as an employee or insurance underwriting. This information may be obtained from private and public record sources, including, as appropriate: government agencies and courthouses. If your employment falls under the federal Department of Transportation (“DOT”) and the Federal Motor Carrier Safety Administration (“FMCSA”), including 49 CFR § 391.23, the report could include your driving, safety inspection and performance history from the FMCSA. Information such as dates of employment, position, accident history, as well as information pertaining to your drug and alcohol testing history, may be requested from each employer in accordance with Section 391.23 and 49 CFR 40.25. Upon written request and provided identification, MVRcheck.com will supply a copy of the completed background report along with a summary of your rights under the Fair Credit Reporting Act, as well as additional information on your rights under the law. MVRcheck.com will process background reports for Company and can be contacted by mail: Compliance@MVRcheck.com or phone: 1-855-865-MVRS. Washington Applicants: Any information contained in the abstract related to an adjudication that is subject to a court order sealing the juvenile record of an employee or prospective employee may not be used by the employer or prospective employer, or an agent authorized to obtain this information on their behalf, unless required by federal regulation or law. By signing below, the party requesting this record certifies through its authorized representative that the information is necessary for employment purposes related to driving by the individual as a condition of employment or otherwise at the direction of the employer. California, Maine, Massachusetts, Minnesota, New Jersey & Oklahoma Applicants: You have the right to request a copy of any Report obtained by Company by emailing Compliance@MVRcheck.com

I have carefully read and understand this disclosure and Authorization form. By my signature below, I hereby authorize MVRcheck.com an agent of the Company to make a thorough background investigation of all information given by me to the Company by preparing a consumer report and/or investigative consumer report. This authorization shall remain on file by Company for the duration of my employment and will serve as ongoing authorization for Company and MVRcheck.com to procure my driving and background records at any time during my employment period. I understand that Company may take adverse action affecting my employment, based on information in my background report. A copy of this form is as valid as the original.