8614 Southeastern Ave.
Indianapolis, IN 46239
12154 N. Saginaw Rd.
Clio, MI 48420
Nashville TN 37219
12813 Industrial Park Blvd.
Plymouth, MN 55441
3119 Merriam LN
Kansas City, KS 66106
1202 Hallmark Drive # 204
San Antonio, Texas 78216
2550 Eastman Ave Ste 6
Ventura, CA 93003
2450 Pleasantdale Rd
Atlanta, GA 30340
2450 Pleasantdale Rd
Atlanta, GA 30340
10311 Orangewood Blvd
Orlando, FL 32821
4628 Crossroads Industrial Drive
St. Louis, MO 63044
13940 N Rivergate Blvd
Portland, OR 97203
8745 Old State Rd.
Holly Hill, SC 29059
9801 Martin Luther King Jr Way S
Seattle WA 98118
2211 Spencerville Rd
Spencerville, MD 20868
1312 Kirkland Road Suite 117
Raliegh, NC 27603
1204 Topside Road
Louisville, TN 37777
1311 Vultee Blvd
Nashville, TN 37217
17517 B Indian Head Hwy Accokeek, MD 20607
419 W. Landstreet Rd.
Orlando, FL 32834
Myrtle Beach, SC 29588
2309 Poplar St
Staunton, VA 24401
21707 8th Street East
Sonoma, CA 95476
1500 Breda Drive
Knoxville, TN 37918
1619 Shepherd Rd.
Chattanooga, TN 37421
408 E Transit St
Ontario, CA 91761
CITY, STATE ZIP
2519 Mitchell St
Knoxville, TN 37917
4211 Fellowship Rd
N. Charleston SC 29418
2300-C Stevens Mill Rd
Charlotte, NC 28104
1454 Willingham Dr.
Atlanta, GA 30344
1810 Water Place SE
Atlanta, GA 30339
1510 Ameron Dr
Charlotte, NC 28206
(The Age Discrimination of Employment Act of 1967 prohibits discrimination on the basis of age with respect to individuals who are at least 40 but less than 70 years of age.)
Maximum number of entries reached.
Note: Please enter the continuous addresses for the past 3 years to go to the next step.
Note: List all employment for the past 3 years, including any unemployment or self-employment periods, volunteer experience, and all commercial driving experience for the past ten (10) years.
**FOR OFFICE STAFF TO FILL OUT – APPLICANT PRINT NAME, SIGN AND DATE AT BOTTOM ONLY **
To (Previous Employer):_______________________________
The person listed above has applied to this company. Your firm is listed by the applicant as a previous employer. Please complete the following items and return to us as soon as possible.
Carrier Representative: Transportation Advisors
Dates of Employment: From________ To________ Position:____________________________
Three-year Accident History
Department of Transportation regulations 40 CFR Part 40.25 h require that you provide the following information:
In the past three years, has the individual listed below ever:
Had a verified positive drug test result? ________Yes ________No
Had an alcohol test result with a breath alcohol concentration of .04 or greater? ________Yes ________No
Refused to submit to an alcohol or drug test? ________Yes ________No
Had any other violations of DOT agency drug and alcohol testing regulations? ________Yes ________No
If any of the above questions were answered yes, please provide the following:
______________________________Substance Abuse Professional
_______________________ Date Referred
Signature of person supplying information
APPLICANT RELEASE AND CONSENT:
do hereby authorize my previous employers to release and forward all information regarding my alcohol and controlled substance testing and all other records of employment to the above-named carrier in connection with my application for employment. I release my former employers from any and all liability of any type as a result of providing the above information.
Parts 383 and 391 of the Federal Motor Carrier Safety Regulations contain certain driver licensing requirements that you as a driver must comply with, including the following:
1) POSSESS ONLY ONE LICENSE: You, as a commercial vehicle driver, may not possess 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 Regulations require that you notify your employer the NEXT BUSINESS DAY of any revocation or suspension of your driver's license. In addition, Section 383.31 requires 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) the state that issued your license (If the violation occurs in a state other than the one which issued your license). The notification to both the employer and the state must be in writing.
3) CDL DOMICILE REQUIREMENT: Section 383.23(a)(2) requires that your commercial driver’s license be issued by your legal state of domicile , where you have your true, fixed, and permanent home and principal residence and to which you have the intention of returning whenever you are absent. If you establish a new domicile in another state, you must apply to transfer your CDL within 30 days.
The following license is the only one I will possess:
Pursuant to 49CFR, part 391.23 (j), you have the following rights regarding investigative information
NOTICE TO DRIVER: The Commercial Driver's License (CDL) Drug & Alcohol Clearinghouse
is a federal database containing information about CDL drivers who have violated the Federal
Motor Carrier Safety Administration's (FMCSA's) drug or alcohol regulations in 49 CFR Part
382. Whether you have committed such a violation or not, each motor carrier for whom you
drive is required to check whether the Clearinghouse has any information about you, both at
the time of hire and annually. When conducting an annual inquiry, the motor carrier has the
option to request a "limited" report that only indicates whether the Clearinghouse has any
information about you; it does not release any violation or testing information. Before a motor
carrier may request a limited report, they must have your written authorization, per
§382.701 (b). This authorization may be valid for more than one year. If a limited query ever
reveals that the Clearinghouse has information about you, you will be required to log in to the
Clearinghouse website within 24 hours to grant electronic consent for the motor carrier to
obtain your full Clearinghouse record.
NOTICE TO MOTOR CARRIER: This consent form authorizes you to run a "limited query" to
check whether the Clearinghouse has information about the driver identified below. If it does,
then you must obtain a full Clearinghouse record within 24 hours, per §382.701 (b). This
consent form must be retained until 3 years after the date of the last limited query you perfonn
for this driver, based on the authorization below.
hereby authorize to conduct limited annual queries of the FMCSA's Drug & Alcohol Clearinghouse, to
determine if a Clearinghouse record exists for me. This consent is valid from the date
shown below until my employment with the above-named motor carrier ceases or until
I am no longer subject to the drug and alcohol testing rules in 49 CFR Part 382 for the
above-named motor carrier.
I understand that if any limited query reveals that the Clearinghouse contains
information about me, I must grant electronic consent within 24 hours, via the
Clearinghouse website, for the motor carrier to obtain my full Clearinghouse record.
Refusal to provide such consent will result in my removal from safety-sensitive duties.
DISCLOSURE TO EMPLOYMENT APPLICANT & STAFF REGARDING INITIAL & ANNUAL PROCUREMENT OF
INVESTIGATIVE & DRIVER’S LICENSE REPORTS: Please be advised that we may obtain an investigative report including information as to your character, general reputation, and personal characteristics. This information may be obtained by contacting your previous employers or references supplied by you. Please be advised that you
have the right to request, in writing, within a reasonable time, that we make a complete and accurate disclosure of
the nature and scope of the information requested. Such disclosure will be made to you within 5 business days of
the date on which we receive the request from you or within 5 business days of the time the report was first
requested. If the individual being reported on is under the age of 18, a guardian’s signature must accompany the
individual’s signature on this form. By signing below, you hereby authorize us to obtain a driver’s license, criminal
background check, education verification, credit report, past employment details, or any other information needed
for employment. We, the employer, reserve the right to pull an updated report at our discretion for a period of five
years or until employment is terminated.
Fair Credit Reporting Act
A Summary of Your Rights
Under the Fair Credit Reporting Act
The Federal Fair Credit Reporting Act (FCRA) is designed to promote accuracy, fairness, and privacy of information in the files of every “consumer reporting agency” (CRA). Most CRA’s are credit bureaus that gather and sell information about you – such as if you pay your bills on time or have filed bankruptcy – to creditors, employers, landlords, and other businesses. You can find the complete text of the FCRA, 15 U.S.C. section 1681-1681u. The FCRA gives you specific rights as outlined below. You may have additional rights under state law. You may contact a state or local consumer protection agency or state attorney general to learn those rights.
For questions and concerns regarding CRA’s, contact:
Federal Trade Commission – Consumer Response Center FCRA
Washington, DC 20580
In compliance with consumer reporting and privacy legislation, I having signed below, authorize
Nationwide Testing Association, Inc. and any of their agents on behalf of the company listed above to
acquire information on my behalf:
ALCOHOL & DRUG SCREENING REQUIREMENT: Controlled Substance and Alcohol Use Testing under Part 382 of the Federal Motor Carrier Safety Regulations apply to all applicants and drivers of . This consent agreement outlines what notification and testing is required under this Part by the FMCSR’s, and by our Company.
A Medical Review Officer will maintain the results of all controlled substance tests and positive alcohol confirmation tests. Both Negative and positive results will be reported to . A positive test for alcohol or controlled substances will disqualify a driver from the operation of a commercial motor vehicle. Driver’s who test positive for controlled substances have 72-hours to request that their split sample be tested. Positive alcohol screening results in an automatic re-testing. Several conditions require testing under Part 382. They are as follows:
Types of Controlled Substance Testing:
Types of Alcohol Testing:
NOTICE MUST BE GIVEN UNDER PART 382.113: Before performing an alcohol or controlled substances test under this part, each employer shall notify a driver that the alcohol or controlled substances test is required by this part. No employer shall falsely represent that a test is administered under this part.
PHYSICAL EXAMINATION AGREEMENT: Physical exams are required by the FMCSR’s for commercial drivers. The driver is responsible to keep their physical current. The physical must be completed by certified DOT Examiner.
APPLICANT AGREEMENT: As an applicant for employment with , I understand that Controlled Substance, Alcohol Testing and physical examinations as described above are a condition of my employment.
In connection with your employment or application for employment (including contract for services), consumer reports may be requested from any consumer reporting agency. These reports may include the following types of information: names and dates of previous employers, reason for termination of employment, work experience, accidents, academic history, professional credentials, and drugs/alcohol use. Such reports may contain public record information concerning your driving record, workers' compensation claims, credit, bankruptcy proceedings, criminal records, etc., from federal, state and other agencies which maintain such records; as well as information concerning previous driving record requests made by others from such state agencies and state provided driving records.
You have the right to make a request to the consumer reporting agency, upon proper identification, the nature and substance of all information in its files on you at the time of your request, including the sources of information and the recipients of any reports on you that the consumer reporting agency has previously furnished within the three-year period preceding your request. The contact information for the consumer reporting agency will be provided to upon request.
I AUTHORIZE, WITHOUT RESERVATION, COMPANY NAME, AND/OR ANY PARTY OR AGENCY CONTACTED BY COMPANY NAME, TO FURNISH THE ABOVE MENTIONED INFORMATION. THIS AUTHORIZATION DOES NOT APPLY TO DRUG AND ALCOHOL INFORMATION OBTAINED UNDER PART I.
I hereby consent to your obtaining the above information from a consumer reporting agency and/or any previous employer, and I agree that such information which any consumer reporting agency has or obtains, and my employment history (not DOT Drug and Alcohol information with a specific consent by me) with you if I am hired, will be supplied by and/or the consumer reporting agency to other companies which subscribe to said consumer reporting agency. I hereby authorized procurement of consumer reports(s). If hired or contracted this authorization, for Part II reports only, shall remain on file and shall serve as ongoing authorization for you to procure consumer reports at any time during my employment or contract period.
In connection with your application for employment with (“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 (“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
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