Application for Driver Position

Current & Previous Three Years Addresses

Driving Experience

Accident Record for past three (3) years

Rights

Pursuant to 49CFR, part 391.23 (j), you have the following rights regarding investigative information

• The right to review information provided by previous employers.
• The right to have errors in the information corrected by the previous employer and for that previous employer to re-send the corrected information to the prospective employer.
• The right to have a rebuttal statement attached to the alleged erroneous information, if the previous employer and the driver cannot agree on the accuracy of the information.

Rights

Pursuant to 49CFR, part 391.23 (j), you have the following rights regarding investigative information

• The right to review information provided by previous employers.
• The right to have errors in the information corrected by the previous employer and for that previous employer to re-send the corrected information to the prospective employer.
• The right to have a rebuttal statement attached to the alleged erroneous information, if the previous employer and the driver cannot agree on the accuracy of the information.

DRUG & ALCOHOL CLEARINGHOUSE CONSENT FOR LIMITED QUERIES

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.

Electronic Disclosure Form

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.

• You must be told if information in your file has been used against you.
• You can find out what is in your file.
• You can dispute inaccurate information with the CRA.
• Inaccurate information must be corrected or deleted.
• You can dispute inaccurate items with the source of the information.
• Outdated information may not be reported.
• Access to your file is limited.
• Your consent is required for reports that are provided to employers or reports that contain medical information.
• You may choose to exclude your name from CRA lists for unsolicited credit or insurance offers.
• You may seek damages from violators.

For questions and concerns regarding CRA’s, contact:
Federal Trade Commission – Consumer Response Center FCRA
Washington, DC 20580
202-326-3761

In compliance with consumer reporting and privacy legislation, I having signed below, authorize Transportation Advisors, Datasource Background Screening Service and any of their agents on behalf of the company listed above to acquire information on my behalf:

Pre-Employment Urinalysis Consent Agreement Drug & Alcohol Testing Consent Agreement Physical Examination Statement

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:

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.

Consumer Report Disclosure and Release

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.