APPLICATION | DOT





1.Personal Information

Name:

Telephone:

Cell Phone:

Email:

SSN/SID:

Date of Application:

Commercial Driver Applicant:

Birthdate:

Current Address

Address:

From:

To:

Total:

Does this cover your last three years residence?

Second Address

Address:

From:

To:

Total:

Does this cover your last three years residence?

Third Address

Address:

From:

To:

Total:

Does this cover your last three years residence?

Fourth Address

Address:

From:

To:

Total:

Total Years for residence

Total:

 

2. Employment Type Desired

Full time or Part-time desired? 

Were you referred by someone and if so, whom? 

Have you worked for this company before? 

If you have worked for this Company Before, Why did you leave? 

Date of employment from: 

Date of employment to: 

How will you get to work? 

Are you willing to work any shift, including nights and weekends? 

Please explain any limitations: 

If Applicable, are you willing to work Overtime? 

If Offered Employment, when would you be able to begin work? 

Are you able to perform the essential function of the job position you seek with or without reasonable accommodation? 

What reasonable accommodation, if any, would you request? 

3. Salary Desired

Salary Desired: 

Compensation Unit: 

If Hired, are you able to submit proof that you are legally eligible for employment in the united states?  

4. Criminal History

Do you live in a State that prohibits an employer asking about your criminal history?

Have you ever been convicted of a Crime?

Please Explain:

 

5. Military Service

Are you or were you a member of the Military?

Military Branch Served:

Please list any specialized Training and Discharge Status:

Date from:

Date to:

Are you currently enlisted, in the reserves or otherwise still engaged with the military services?:

 

6. License Driving Record

Do you have a CDL (commercial driver's license)?

How many years have you had your CDL?

DRIVER APPLICANTS: Please list all states you have been licensed in within the last FIVE years. Is the license you are listing below the only License you have held within the last five years?

Current Driver's License Number:

Current License Class:

Current State of Issue:

Drivers License Expiration Date:

DOL Eye Color Listed on your License:

Endrosements:

DRIVER APPLICANTS: Please list all states you have been licensed in within the last FIVE years. Does license you are listing below complete the licenses you have held in the last five years?

Driver License Number:

State of Issue:

Expiration Date:

Date of Birth:

Gender on license:

Hair Color on License:

Section 383.21 FMCSR states "No person who operates a commercial motor vehicle shall at any time have more than one driver's license". I certify I do not have more than one motor vehicle license, the information for which is listed below.

 

7. Ethnicity and Race

Ethnicity and race information is requested under the authority of 42 U.S.C. Section 2000e-16 and in compliance with the Office of Management and Budget's 1997 Revisions to the Standards for the Classification of Federal Data on Race and Ethnicity. Providing this information is voluntary and has no impact on your employment status, but in the instance
of missing information, your employing agency will attempt to identify your race and ethnicity by visual observation.

This information is used as necessary to plan for equal employment opportunity throughout the Federal government. It is also used by the U. S. Office of Personnel Management or employing agency maintaining the records to locate individuals for personnel research or survey response and in the production of summary descriptive statistics and analytical studies in support of the function for which the records are collected and maintained, or for related workforce studies.

Social Security Number (SSN) is requested under the authority of Executive Order 9397, which requires SSN be used for the purpose of uniform, orderly administration of personnel records. Providing this information is voluntary and failure to do so will have no effect on your employment status. If SSN is not provided, however, other agency sources may be used to obtain it.

Question 1. Are You Hispanic or Latino?

Question 2. Please select the racial category or categories with which you most closely identify.

Height:

Weight:

8. Previous Employment Summary

1. Employer:

Date From:

Date To:

Supervisor Name:

Were you subject to the FMCSRs while employed by this previous employer?

Was this Job designated as a safety sensitive function in any DOT regulated mode?

Company Phone:

Does this complete your ten year history?

2. Employer:

Date From:

Date To:

Supervisor Name:

Were you subject to the FMCSRs while employed by this previous employer?

Was this Job designated as a safety sensitive function in any DOT regulated mode?

Company Phone:

Does this complete your ten year history?

3. Employer:

Date From:

Date To:

Supervisor Name:

Were you subject to the FMCSRs while employed by this previous employer?

Was this Job designated as a safety sensitive function in any DOT regulated mode?

Company Phone:

Does this complete your ten year history?

4. Employer:

Date From:

Date To:

Supervisor Name:

Were you subject to the FMCSRs while employed by this previous employer?

Was this Job designated as a safety sensitive function in any DOT regulated mode?

Company Phone:

Does this complete your ten year history?

5. Employer:

Date From:

Date To:

Supervisor Name:

Were you subject to the FMCSRs while employed by this previous employer?

Was this Job designated as a safety sensitive function in any DOT regulated mode?

Company Phone:

Does this complete your ten year history?

6. Employer:

Date From:

Date To:

Supervisor Name:

Were you subject to the FMCSRs while employed by this previous employer?

Was this Job designated as a safety sensitive function in any DOT regulated mode?

Company Phone:

Does this complete your ten year history?

7. Employer:

Date From:

Date To:

Supervisor Name:

Were you subject to the FMCSRs while employed by this previous employer?

Was this Job designated as a safety sensitive function in any DOT regulated mode?

Company Phone:

Does this complete your ten year history?

8. Employer:

Date From:

Date To:

Supervisor Name:

Were you subject to the FMCSRs while employed by this previous employer?

Was this Job designated as a safety sensitive function in any DOT regulated mode?

Company Phone:

Does this complete your ten year history?

9. Employer:

Date From:

Date To:

Supervisor Name:

Were you subject to the FMCSRs while employed by this previous employer?

Was this Job designated as a safety sensitive function in any DOT regulated mode?

Company Phone:

Does this complete your ten year history?

10. Employer:

Date From:

Date To:

Supervisor Name:

Were you subject to the FMCSRs while employed by this previous employer?

Was this Job designated as a safety sensitive function in any DOT regulated mode?

Company Phone:

Did you drive any commercial vehicles for any company in the last ten years that you were unable to list above?

Total years employment history provided:

11. References

First Reference

Name:

Phone:

Address:

Relationship:

Second Reference

Name:

Phone:

Address:

Relationship:

 

12. Driving Experience and Equipment Experience

What Types of CMV have you experience Operating? 

Motorcoach:

Minicoach:

Straight Truck:

Dump Truck:

Semi-Trailers:

Semi-Doubles/Triples:

Semi-Tankers or HAZMAT:

Semi-Flatbed:

Other Equipment Type:  

How Many Accidents have you had in last the three years?:

First Accident

1. Nature of Accident:

Date of Occurrence:

Were Fatalities or Personal Injuries Sustained:

Was this a Reportable DOT Accident?

Second Accident

2. Nature of Accident:

Date of Occurrence:

Were Fatalities or Personal Injuries Sustained:

Was this a Reportable DOT Accident?

Third Accident

3. Nature of Accident:

Date of Occurrence:

Were Fatalities or Personal Injuries Sustained:

Was this a Reportable DOT Accident?

Fourth Accident

4. Nature of Accident:

Date of Occurrence:

Were Fatalities or Personal Injuries Sustained:

Was this a Reportable DOT Accident?

How Many Violations have you had in last the three years?:

First Violation

1. Nature of Violation:

Date of Occurrence:

Was this in a Commercial Motor Vehicle? 

Were Fatalities or Personal Injuries Sustained? 

Second Violation

2. Nature of Violation:

Date of Occurrence:

Was this in a Commercial Motor Vehicle?

Were Fatalities or Personal Injuries Sustained?

Third Violation

3. Nature of Violation:

Date of Occurrence:

Was this in a Commercial Motor Vehicle? 

Were Fatalities or Personal Injuries Sustained?

 

CFR 49 Previous Employer Drug, Alcohol and Safety Request for information 1

Applicants that desire to drive in intrastate/interstate commerce must provide the following information on ALL EMPLOYERS during the previous three years. Additionally, you must provide the same information for all employers you HAVE DRIVEN A COMMERCIAL MOTOR VEHICLE for the seven years prior to the initial three years (total of ten years employment record for CDL drivers)

SECTION 1: To be completed by the applicant for submission to the previous employer. All fields are required.

Requesting Company Name:

Applicant Name:

Applicant Address:

Applicant Telephone:

Applicant Email Address:

Previous Employer:

Previous Employer Manager:

Previous Employer Address:        

Previous Employer Telephone:

Previous Employer FAX:  

Previous Employer Email:

Employed From:

Employed to: (enter current date if still employed):

Do you intend to remain employed with this employer:

Final hourly rate of Pay:

Reason for Leaving:

Were you subject to the Federal Motor Carrier Safety Regulations (FMCSRs) While employed by this employer?

Was the previous job position designated as a safety sensitive function in any DOT regulated mode, subject to alcohol and controlled substances testing requirements as required by 49 CFR Part 49?

SECTION 2: To be completed by the applicant. As required by CFR 49 Part 391.23(c), we are forwarding this inquiry on the above named person who has made application to the above referenced company for employment as a commercial vehicle operator or mechanic. We respectfully request that you reply to this inquiry to the extent that your company policy allows, regarding this applicant. The applicant has signed the attached liability release for your records.

RELEASE of INFORMATION Form-49 CFR Part 40 Drug and Alcohol Testing:  I hereby authorize the release of information from my Department of Transportation regulated drug and alcohol testing records by my previous employer listed in Section 1, to the employer listed in the header section. This release is in accordance with DOT Regulation 49 CFR Part 40,  Section 40.25. I understand that information to be released in Section 3 by my previous employer is limited to the following DOT regulated testing items.

Items to be released: Alcohol Tests with a result of 0.04 or higher, Verified positive drug tests, Refusals to be tested, Other violations of DOT agency drug and alcohol testing regulations, Information obtained from previous employers of a drug and alcohol rule violations, and Documentation, if any, of completion of the return-to-duty process following a rule violation.

SECTION 3: To be completed by the previous Employer and transmitted by mail, please fax or email to the new employer. Fax, Mail or Email with the information listed at top of the page.

Did the employee have alcohol tests with a drug result of 0.04 or higher?                                                               

Yes        No

Did the employee have verified positive drug results?                                                                                                   

Yes        No

Did the employee refuse to be tested?                                                                                                                               

Yes        No

Did the employee have other violations of DOT agency drug and alcohol testing rules?                                       

Yes        No

Did a previous employer report a drug or alcohol rule violation to you?                                                                   

Yes       No

If you answered yes to any of the above items, did the employee complete the return-to-duty process?           

Yes       No

NOTE:  If you answered yes to item 5, you MUST provide the previous employer's report. If you answered "yes" to item 6, you must also transmit the appropriate return-to-duty documentation

(e.g., SAP report(s), follow-up testing record).

SECTION 4: To be completed by previous Employer

Employee was Employed From:   _________________ 

Employee was Employed to:  _____________________

Reason For leaving:__________________________________________________________

Number of Accidents: ________________________________________________________    

Preventable: _______________________________________________________________

Was applicant's Drivers License ever suspended or revoked?                                                                                   

Yes       No

Was applicant's general conduct satisfactory?                                                                                                             

Yes       No

Was there a history of absenteeism or tardiness on this applicant?                                                                       

Yes       No

Did this applicant give adequate notice prior to leaving your employment?                                                         

Yes       No

It is a violation of our policy to release information other than that information provided here.                     

Yes       No

Federal law requires that DOT regulated employers respond in a timely manner to these requests. If a previous employer fails to respond to the request, it is the requirement of law that the potential or new employer submit documentation that a previous employer failed to respond to the CFR 49 Drug and Alcohol Request.

Employer representative completing form: __________________________________________

Signature: ________________________________________________________________

Date Completed: ___________

Telephone Number of Representative: ______________________

Title of Representative: _______________________________________________________

PLEASE SEND INFORMATION TO:  

CFR 49 Previous Employer Drug, Alcohol and Safety Request for information 2

Applicants that desire to drive in intrastate/interstate commerce must provide the following information on ALL EMPLOYERS during the previous three years. Additionally, you must provide the same information for all employers you HAVE DRIVEN A COMMERCIAL MOTOR VEHICLE for the seven years prior to the initial three years (total of ten years employment record for CDL drivers)

SECTION 1: To be completed by the applicant for submission to the previous employer. All fields are required.

Requesting Company Name:

Applicant Name:

Applicant Address:

Applicant Telephone:

Applicant Email Address:

Previous Employer:

Previous Employer Manager:

Previous Employer Address:        

Previous Employer Telephone:

Previous Employer FAX:  

Previous Employer Email:

Employed From:

Employed to: (enter current date if still employed):

Final hourly rate of Pay:

Reason for Leaving:

Were you subject to the Federal Motor Carrier Safety Regulations (FMCSRs) While employed by this employer?

Was the previous job position designated as a safety-sensitive function in any DOT regulated mode, subject to alcohol and controlled substances testing requirements as required by 49 CFR Part 49?

SECTION 2: To be completed by the applicant. As required by CFR 49 Part 391.23(c), we are forwarding this inquiry on the above-named person who has made application to the above-referenced company for employment as a commercial vehicle operator or mechanic. We respectfully request that you reply to this inquiry to the extent that your company policy allows, regarding this applicant. The applicant has signed the attached liability release for your records.

RELEASE of INFORMATION Form-49 CFR Part 40 Drug and Alcohol Testing:  I hereby authorize the release of information from my Department of Transportation regulated drug and alcohol testing records by my previous employer listed in Section 1, to the employer listed in the header section. This release is in accordance with DOT Regulation 49 CFR Part 40,  Section 40.25. I understand that information to be released in Section 3 by my previous employer is limited to the following DOT regulated testing items.

Items to be released: Alcohol Tests with a result of 0.04 or higher, Verified positive drug tests, Refusals to be tested, Other violations of DOT agency drug and alcohol testing regulations, Information obtained from previous employers of a drug and alcohol rule violations, and Documentation, if any, of completion of the return-to-duty process following a rule violation.

SECTION 3: To be completed by the previous Employer and transmitted by mail, please fax or email to the new employer. Fax, Mail or Email with the information listed at top of the page.

Did the employee have alcohol tests with a drug result of 0.04 or higher?                                                               

Yes        No

Did the employee have verified positive drug results?                                                                                                   

Yes        No

Did the employee refuse to be tested?                                                                                                                               

Yes        No

Did the employee have other violations of DOT agency drug and alcohol testing rules?                                       

Yes        No

Did a previous employer report a drug or alcohol rule violation to you?                                                                   

Yes       No

If you answered yes to any of the above items, did the employee complete the return-to-duty process?           

Yes       No

NOTE:  If you answered yes to item 5, you MUST provide the previous employer's report. If you answered "yes" to item 6, you must also transmit the appropriate return-to-duty documentation

(e.g., SAP report(s), follow-up testing record).

SECTION 4: To be completed by previous Employer

Employee was Employed From:   _________________ 

Employee was Employed to:  _____________________

Reason For leaving:__________________________________________________________

Number of Accidents: ________________________________________________________    

Preventable: _______________________________________________________________

Was applicant's Drivers License ever suspended or revoked?                                                                                 

 Yes       No

Was applicant's general conduct satisfactory?                                                                                                             

Yes       No

Was there a history of absenteeism or tardiness on this applicant?                                                                       

 Yes       No

Did this applicant give adequate notice prior to leaving your employment?                                                         

Yes       No

It is a violation of our policy to release information other than that information provided here.                     

Yes       No

Federal law requires that DOT regulated employers respond in a timely manner to these requests. If a previous employer fails to respond to the request, it is the requirement of law that the potential or new employer submit documentation that a previous employer failed to respond to the CFR 49 Drug and Alcohol Request.

Employer representative completing form: __________________________________________

Signature: ________________________________________________________________

Date Completed: ___________

Telephone Number of Representative: ______________________

Title of Representative: _______________________________________________________

PLEASE SEND INFORMATION TO:   

CFR 49 Previous Employer Drug, Alcohol and Safety Request for information 3

Applicants that desire to drive in intrastate/interstate commerce must provide the following information on ALL EMPLOYERS during the previous three years. Additionally, you must provide the same information for all employers you HAVE DRIVEN A COMMERCIAL MOTOR VEHICLE for the seven years prior to the initial three years (total of ten years employment record for CDL drivers)

SECTION 1: To be completed by the applicant for submission to the previous employer. All fields are required.

Requesting Company Name:

Applicant Name:

Applicant Address:

Applicant Telephone:

Applicant Email Address:

Previous Employer:

Previous Employer Manager:

Previous Employer Address:        

Previous Employer Telephone:

Previous Employer FAX:  

Previous Employer Email:

Employed From:

Employed to: (enter current date if still employed):

Final hourly rate of Pay:

Reason for Leaving:

Were you subject to the Federal Motor Carrier Safety Regulations (FMCSRs) While employed by this employer?

Was the previous job position designated as a safety sensitive function in any DOT regulated mode, subject to alcohol and controlled substances testing requirements as required by 49 CFR Part 49?

SECTION 2: To be completed by the applicant. As required by CFR 49 Part 391.23(c), we are forwarding this inquiry on the above named person who has made application to the above referenced company for employment as a commercial vehicle operator or mechanic. We respectfully request that you reply to this inquiry to the extent that your company policy allows, regarding this applicant. The applicant has signed the attached liability release for your records.

RELEASE of INFORMATION Form-49 CFR Part 40 Drug and Alcohol Testing:  I hereby authorize the release of information from my Department of Transportation regulated drug and alcohol testing records by my previous employer listed in Section 1, to the employer listed in the header section. This release is in accordance with DOT Regulation 49 CFR Part 40,  Section 40.25. I understand that information to be released in Section 3 by my previous employer is limited to the following DOT regulated testing items.

Items to be released: Alcohol Tests with a result of 0.04 or higher, Verified positive drug tests, Refusals to be tested, Other violations of DOT agency drug and alcohol testing regulations, Information obtained from previous employers of a drug and alcohol rule violations, and Documentation, if any, of completion of the return-to-duty process following a rule violation.

SECTION 3: To be completed by the previous Employer and transmitted by mail, please fax or email to the new employer. Fax, Mail or Email with the information listed at top of the page.

Did the employee have alcohol tests with a drug result of 0.04 or higher?                                                               

Yes        No

Did the employee have verified positive drug results?                                                                                                   

Yes        No

Did the employee refuse to be tested?                                                                                                                               

Yes        No

Did the employee have other violations of DOT agency drug and alcohol testing rules?                                       

Yes        No

Did a previous employer report a drug or alcohol rule violation to you?                                                                   

Yes       No

If you answered yes to any of the above items, did the employee complete the return-to-duty process?         

Yes       No

NOTE:  If you answered yes to item 5, you MUST provide the previous employer's report. If you answered "yes" to item 6, you must also transmit the appropriate return-to-duty documentation

(e.g., SAP report(s), follow-up testing record).

SECTION 4: To be completed by previous Employer

Employee was Employed From:   _________________ 

Employee was Employed to:  _____________________

Reason For leaving:__________________________________________________________

Number of Accidents: ________________________________________________________    

Preventable: _______________________________________________________________

Was applicant's Drivers License ever suspended or revoked?                                                                                   

Yes       No

Was applicant's general conduct satisfactory?                                                                                                             

Yes       No

Was there a history of absenteeism or tardiness on this applicant?                                                                         

Yes       No

Did this applicant give adequate notice prior to leaving your employment?                                                         

Yes       No

It is a violation of our policy to release information other than that information provided here.                     

Yes       No

Federal law requires that DOT regulated employers respond in a timely manner to these requests. If a previous employer fails to respond to the request, it is the requirement of law that the potential or new employer submit documentation that a previous employer failed to respond to the CFR 49 Drug and Alcohol Request.

Employer representative completing form: __________________________________________

Signature: ________________________________________________________________

Date Completed: ___________

Telephone Number of Representative: ______________________

Title of Representative: _______________________________________________________

 PLEASE SEND INFORMATION TO:  

CFR 49 Previous Employer Drug, Alcohol and Safety Request for information 4

Applicants that desire to drive in intrastate/interstate commerce must provide the following information on ALL EMPLOYERS during the previous three years. Additionally, you must provide the same information for all employers you HAVE DRIVEN A COMMERCIAL MOTOR VEHICLE for the seven years prior to the initial three years (total of ten years employment record for CDL drivers)

SECTION 1: To be completed by the applicant for submission to the previous employer. All fields are required.

Requesting Company Name:

Applicant Name:

Applicant Address:

Applicant Telephone:

Applicant Email Address:

Previous Employer:

Previous Employer Manager:

Previous Employer Address:        

Previous Employer Telephone:

Previous Employer FAX:  

Previous Employer Email:

Employed From:

Employed to: (enter current date if still employed):

Final hourly rate of Pay:

Reason for Leaving:

Were you subject to the Federal Motor Carrier Safety Regulations (FMCSRs) While employed by this employer?

Was the previous job position designated as a safety sensitive function in any DOT regulated mode, subject to alcohol and controlled substances testing requirements as required by 49 CFR Part 49?

SECTION 2: To be completed by the applicant. As required by CFR 49 Part 391.23(c), we are forwarding this inquiry on the above named person who has made application to the above referenced company for employment as a commercial vehicle operator or mechanic. We respectfully request that you reply to this inquiry to the extent that your company policy allows, regarding this applicant. The applicant has signed the attached liability release for your records.

RELEASE of INFORMATION Form-49 CFR Part 40 Drug and Alcohol Testing:  I hereby authorize the release of information from my Department of Transportation regulated drug and alcohol testing records by my previous employer listed in Section 1, to the employer listed in the header section. This release is in accordance with DOT Regulation 49 CFR Part 40,  Section 40.25. I understand that information to be released in Section 3 by my previous employer is limited to the following DOT regulated testing items.

Items to be released: Alcohol Tests with a result of 0.04 or higher, Verified positive drug tests, Refusals to be tested, Other violations of DOT agency drug and alcohol testing regulations, Information obtained from previous employers of a drug and alcohol rule violations, and Documentation, if any, of completion of the return-to-duty process following a rule violation.

SECTION 3: To be completed by the previous Employer and transmitted by mail, please fax or email to the new employer. Fax, Mail or Email with the information listed at top of the page.

Did the employee have alcohol tests with a drug result of 0.04 or higher?                                                               

Yes        No

Did the employee have verified positive drug results?                                                                                                   

Yes        No

Did the employee refuse to be tested?                                                                                                                               

Yes        No

Did the employee have other violations of DOT agency drug and alcohol testing rules?                                       

Yes        No

Did a previous employer report a drug or alcohol rule violation to you?                                                                   

Yes       No

If you answered yes to any of the above items, did the employee complete the return-to-duty process?           

Yes       No

NOTE:  If you answered yes to item 5, you MUST provide the previous employer's report. If you answered "yes" to item 6, you must also transmit the appropriate return-to-duty documentation

(e.g., SAP report(s), follow-up testing record).

SECTION 4: To be completed by previous Employer

Employee was Employed From:   _________________ 

Employee was Employed to:  _____________________

Reason For leaving:__________________________________________________________

Number of Accidents: ________________________________________________________    

Preventable: _______________________________________________________________

Was applicant's Drivers License ever suspended or revoked?                                                                                   

Yes       No

Was applicant's general conduct satisfactory?                                                                                                             

Yes       No

Was there a history of absenteeism or tardiness on this applicant?                                                                         

Yes       No

Did this applicant give adequate notice prior to leaving your employment?                                                         

Yes       No

It is a violation of our policy to release information other than that information provided here.                     

Yes       No

Federal law requires that DOT regulated employers respond in a timely manner to these requests. If a previous employer fails to respond to the request, it is the requirement of law that the potential or new employer submit documentation that a previous employer failed to respond to the CFR 49 Drug and Alcohol Request.

Employer representative completing form: __________________________________________

Signature: ________________________________________________________________

Date Completed: ___________

Telephone Number of Representative: ______________________

Title of Representative: _______________________________________________________

 PLEASE SEND INFORMATION TO:  

CFR 49 Previous Employer Drug, Alcohol and Safety Request for information 5

Applicants that desire to drive in intrastate/interstate commerce must provide the following information on ALL EMPLOYERS during the previous three years. Additionally, you must provide the same information for all employers you HAVE DRIVEN A COMMERCIAL MOTOR VEHICLE for the seven years prior to the initial three years (total of ten years employment record for CDL drivers)

SECTION 1: To be completed by the applicant for submission to the previous employer. All fields are required.

Requesting Company Name:

Applicant Name:

Applicant Address:

Applicant Telephone:

Applicant Email Address:

Previous Employer:

Previous Employer Manager:

Previous Employer Address:        

Previous Employer Telephone:

Previous Employer FAX:  

Previous Employer Email:

Employed From:

Employed to: (enter current date if still employed):

Final hourly rate of Pay:

Reason for Leaving:

Were you subject to the Federal Motor Carrier Safety Regulations (FMCSRs) While employed by this employer?

Was the previous job position designated as a safety sensitive function in any DOT regulated mode, subject to alcohol and controlled substances testing requirements as required by 49 CFR Part 49?

SECTION 2: To be completed by the applicant. As required by CFR 49 Part 391.23(c), we are forwarding this inquiry on the above named person who has made application to the above referenced company for employment as a commercial vehicle operator or mechanic. We respectfully request that you reply to this inquiry to the extent that your company policy allows, regarding this applicant. The applicant has signed the attached liability release for your records.

RELEASE of INFORMATION Form-49 CFR Part 40 Drug and Alcohol Testing:  I hereby authorize the release of information from my Department of Transportation regulated drug and alcohol testing records by my previous employer listed in Section 1, to the employer listed in the header section. This release is in accordance with DOT Regulation 49 CFR Part 40,  Section 40.25. I understand that information to be released in Section 3 by my previous employer is limited to the following DOT regulated testing items.

Items to be released: Alcohol Tests with a result of 0.04 or higher, Verified positive drug tests, Refusals to be tested, Other violations of DOT agency drug and alcohol testing regulations, Information obtained from previous employers of a drug and alcohol rule violations, and Documentation, if any, of completion of the return-to-duty process following a rule violation.

SECTION 3: To be completed by the previous Employer and transmitted by mail, please fax or email to the new employer. Fax, Mail or Email with the information listed at top of the page.

Did the employee have alcohol tests with a drug result of 0.04 or higher?                                                               

Yes        No

Did the employee have verified positive drug results?                                                                                                   

Yes        No

Did the employee refuse to be tested?                                                                                                                               

Yes        No

Did the employee have other violations of DOT agency drug and alcohol testing rules?                                       

Yes        No

Did a previous employer report a drug or alcohol rule violation to you?                                                                   

Yes       No

If you answered yes to any of the above items, did the employee complete the return-to-duty process?           

Yes       No

NOTE:  If you answered yes to item 5, you MUST provide the previous employer's report. If you answered "yes" to item 6, you must also transmit the appropriate return-to-duty documentation

(e.g., SAP report(s), follow-up testing record).

SECTION 4: To be completed by previous Employer

Employee was Employed From:   _________________ 

Employee was Employed to:  _____________________

Reason For leaving:__________________________________________________________

Number of Accidents: ________________________________________________________    

Preventable: _______________________________________________________________

Was applicant's Drivers License ever suspended or revoked?                                                                                 

 Yes       No

Was applicant's general conduct satisfactory?                                                                                                             

Yes       No

Was there a history of absenteeism or tardiness on this applicant?                                                                         

Yes       No

Did this applicant give adequate notice prior to leaving your employment?                                                         

Yes       No

It is a violation of our policy to release information other than that information provided here.                     

Yes       No

Federal law requires that DOT regulated employers respond in a timely manner to these requests. If a previous employer fails to respond to the request, it is the requirement of law that the potential or new employer submit documentation that a previous employer failed to respond to the CFR 49 Drug and Alcohol Request.

Employer representative completing form: __________________________________________

Signature: ________________________________________________________________

Date Completed: ___________

Telephone Number of Representative: ______________________

Title of Representative: _______________________________________________________

PLEASE SEND INFORMATION TO:   

CFR 49 Previous Employer Drug, Alcohol and Safety Request for information 6

Applicants that desire to drive in intrastate/interstate commerce must provide the following information on ALL EMPLOYERS during the previous three years. Additionally, you must provide the same information for all employers you HAVE DRIVEN A COMMERCIAL MOTOR VEHICLE for the seven years prior to the initial three years (total of ten years employment record for CDL drivers)

SECTION 1: To be completed by the applicant for submission to the previous employer. All fields are required.

Requesting Company Name:

Applicant Name:

Applicant Address:

Applicant Telephone:

Applicant Email Address:

Previous Employer:

Previous Employer Manager:

Previous Employer Address:        

Previous Employer Telephone:

Previous Employer FAX:  

Previous Employer Email:

Employed From:

Employed to: (enter current date if still employed):

Final hourly rate of Pay:

Reason for Leaving:

Were you subject to the Federal Motor Carrier Safety Regulations (FMCSRs) While employed by this employer?

Was the previous job position designated as a safety sensitive function in any DOT regulated mode, subject to alcohol and controlled substances testing requirements as required by 49 CFR Part 49?

SECTION 2: To be completed by the applicant. As required by CFR 49 Part 391.23(c), we are forwarding this inquiry on the above named person who has made application to the above referenced company for employment as a commercial vehicle operator or mechanic. We respectfully request that you reply to this inquiry to the extent that your company policy allows, regarding this applicant. The applicant has signed the attached liability release for your records.

RELEASE of INFORMATION Form-49 CFR Part 40 Drug and Alcohol Testing:  I hereby authorize the release of information from my Department of Transportation regulated drug and alcohol testing records by my previous employer listed in Section 1, to the employer listed in the header section. This release is in accordance with DOT Regulation 49 CFR Part 40,  Section 40.25. I understand that information to be released in Section 3 by my previous employer is limited to the following DOT regulated testing items.

Items to be released: Alcohol Tests with a result of 0.04 or higher, Verified positive drug tests, Refusals to be tested, Other violations of DOT agency drug and alcohol testing regulations, Information obtained from previous employers of a drug and alcohol rule violations, and Documentation, if any, of completion of the return-to-duty process following a rule violation.

SECTION 3: To be completed by the previous Employer and transmitted by mail, please fax or email to the new employer. Fax, Mail or Email with the information listed at top of the page.

Did the employee have alcohol tests with a drug result of 0.04 or higher?                                                               

Yes        No

Did the employee have verified positive drug results?                                                                                                   

Yes        No

Did the employee refuse to be tested?                                                                                                                               

Yes        No

Did the employee have other violations of DOT agency drug and alcohol testing rules?                                       

Yes        No

Did a previous employer report a drug or alcohol rule violation to you?                                                                   

Yes       No

If you answered yes to any of the above items, did the employee complete the return-to-duty process?           

Yes       No

NOTE:  If you answered yes to item 5, you MUST provide the previous employer's report. If you answered "yes" to item 6, you must also transmit the appropriate return-to-duty documentation

(e.g., SAP report(s), follow-up testing record).

SECTION 4: To be completed by previous Employer

Employee was Employed From:   _________________ 

Employee was Employed to:  _____________________

Reason For leaving:__________________________________________________________

Number of Accidents: ________________________________________________________    

Preventable: _______________________________________________________________

Was applicant's Drivers License ever suspended or revoked?                                                                                   

Yes       No

Was applicant's general conduct satisfactory?                                                                                                             

Yes       No

Was there a history of absenteeism or tardiness on this applicant?                                                                         

Yes       No

Did this applicant give adequate notice prior to leaving your employment?                                                         

Yes       No

It is a violation of our policy to release information other than that information provided here.                     

Yes       No

Federal law requires that DOT regulated employers respond in a timely manner to these requests. If a previous employer fails to respond to the request, it is the requirement of law that the potential or new employer submit documentation that a previous employer failed to respond to the CFR 49 Drug and Alcohol Request.

Employer representative completing form: __________________________________________

Signature: ________________________________________________________________

Date Completed: ___________

Telephone Number of Representative: ______________________

Title of Representative: _______________________________________________________

PLEASE SEND INFORMATION TO:  

CFR 49 Previous Employer Drug, Alcohol and Safety Request for information 7

Applicants that desire to drive in intrastate/interstate commerce must provide the following information on ALL EMPLOYERS during the previous three years. Additionally, you must provide the same information for all employers you HAVE DRIVEN A COMMERCIAL MOTOR VEHICLE for the seven years prior to the initial three years (total of ten years employment record for CDL drivers)

SECTION 1: To be completed by the applicant for submission to the previous employer. All fields are required.

Requesting Company Name:

Applicant Name:

Applicant Address:

Applicant Telephone:

Applicant Email Address:

Previous Employer:

Previous Employer Manager:

Previous Employer Address:        

Previous Employer Telephone:

Previous Employer FAX:  

Previous Employer Email:

Employed From:

Employed to: (enter current date if still employed):

Final hourly rate of Pay:

Reason for Leaving:

Were you subject to the Federal Motor Carrier Safety Regulations (FMCSRs) While employed by this employer?

Was the previous job position designated as a safety sensitive function in any DOT regulated mode, subject to alcohol and controlled substances testing requirements as required by 49 CFR Part 49?

SECTION 2: To be completed by the applicant. As required by CFR 49 Part 391.23(c), we are forwarding this inquiry on the above named person who has made application to the above referenced company for employment as a commercial vehicle operator or mechanic. We respectfully request that you reply to this inquiry to the extent that your company policy allows, regarding this applicant. The applicant has signed the attached liability release for your records.

RELEASE of INFORMATION Form-49 CFR Part 40 Drug and Alcohol Testing:  I hereby authorize the release of information from my Department of Transportation regulated drug and alcohol testing records by my previous employer listed in Section 1, to the employer listed in the header section. This release is in accordance with DOT Regulation 49 CFR Part 40,  Section 40.25. I understand that information to be released in Section 3 by my previous employer is limited to the following DOT regulated testing items.

Items to be released: Alcohol Tests with a result of 0.04 or higher, Verified positive drug tests, Refusals to be tested, Other violations of DOT agency drug and alcohol testing regulations, Information obtained from previous employers of a drug and alcohol rule violations, and Documentation, if any, of completion of the return-to-duty process following a rule violation.

SECTION 3: To be completed by the previous Employer and transmitted by mail, please fax or email to the new employer. Fax, Mail or Email with the information listed at top of the page.

Did the employee have alcohol tests with a drug result of 0.04 or higher?                                                               

Yes        No

Did the employee have verified positive drug results?                                                                                                   

Yes        No

Did the employee refuse to be tested?                                                                                                                               

Yes        No

Did the employee have other violations of DOT agency drug and alcohol testing rules?                                       

Yes        No

Did a previous employer report a drug or alcohol rule violation to you?                                                                   

Yes       No

If you answered yes to any of the above items, did the employee complete the return-to-duty process?           

Yes       No

NOTE:  If you answered yes to item 5, you MUST provide the previous employer's report. If you answered "yes" to item 6, you must also transmit the appropriate return-to-duty documentation

(e.g., SAP report(s), follow-up testing record).

SECTION 4: To be completed by previous Employer

Employee was Employed From:   _________________ 

Employee was Employed to:  _____________________

Reason For leaving:__________________________________________________________

Number of Accidents: ________________________________________________________    

Preventable: _______________________________________________________________

Was applicant's Drivers License ever suspended or revoked?                                                                                   

Yes       No

Was applicant's general conduct satisfactory?                                                                                                             

Yes       No

Was there a history of absenteeism or tardiness on this applicant?                                                                         

Yes       No

Did this applicant give adequate notice prior to leaving your employment?                                                         

Yes       No

It is a violation of our policy to release information other than that information provided here.                     

Yes       No

Federal law requires that DOT regulated employers respond in a timely manner to these requests. If a previous employer fails to respond to the request, it is the requirement of law that the potential or new employer submit documentation that a previous employer failed to respond to the CFR 49 Drug and Alcohol Request.

Employer representative completing form: __________________________________________

Signature: ________________________________________________________________

Date Completed: ___________

Telephone Number of Representative: ______________________

Title of Representative: _______________________________________________________

PLEASE SEND INFORMATION TO:  

CFR 49 Previous Employer Drug, Alcohol and Safety Request for information 8

Applicants that desire to drive in intrastate/interstate commerce must provide the following information on ALL EMPLOYERS during the previous three years. Additionally, you must provide the same information for all employers you HAVE DRIVEN A COMMERCIAL MOTOR VEHICLE for the seven years prior to the initial three years (total of ten years employment record for CDL drivers)

SECTION 1: To be completed by the applicant for submission to the previous employer. All fields are required.

Requesting Company Name:

Applicant Name:

Applicant Address:

Applicant Telephone:

Applicant Email Address:

Previous Employer:

Previous Employer Manager:

Previous Employer Address:        

Previous Employer Telephone:

Previous Employer FAX:  

Previous Employer Email:

Employed From:

Employed to: (enter current date if still employed):

Final hourly rate of Pay:

Reason for Leaving:

Were you subject to the Federal Motor Carrier Safety Regulations (FMCSRs) While employed by this employer?

Was the previous job position designated as a safety sensitive function in any DOT regulated mode, subject to alcohol and controlled substances testing requirements as required by 49 CFR Part 49?

SECTION 2: To be completed by the applicant. As required by CFR 49 Part 391.23(c), we are forwarding this inquiry on the above named person who has made application to the above referenced company for employment as a commercial vehicle operator or mechanic. We respectfully request that you reply to this inquiry to the extent that your company policy allows, regarding this applicant. The applicant has signed the attached liability release for your records.

RELEASE of INFORMATION Form-49 CFR Part 40 Drug and Alcohol Testing:  I hereby authorize the release of information from my Department of Transportation regulated drug and alcohol testing records by my previous employer listed in Section 1, to the employer listed in the header section. This release is in accordance with DOT Regulation 49 CFR Part 40,  Section 40.25. I understand that information to be released in Section 3 by my previous employer is limited to the following DOT regulated testing items.

Items to be released: Alcohol Tests with a result of 0.04 or higher, Verified positive drug tests, Refusals to be tested, Other violations of DOT agency drug and alcohol testing regulations, Information obtained from previous employers of a drug and alcohol rule violations, and Documentation, if any, of completion of the return-to-duty process following a rule violation.

SECTION 3: To be completed by the previous Employer and transmitted by mail, please fax or email to the new employer. Fax, Mail or Email with the information listed at top of the page.

Did the employee have alcohol tests with a drug result of 0.04 or higher?                                                               

Yes        No

Did the employee have verified positive drug results?                                                                                                   

Yes        No

Did the employee refuse to be tested?                                                                                                                               

Yes        No

Did the employee have other violations of DOT agency drug and alcohol testing rules?                                       

Yes        No

Did a previous employer report a drug or alcohol rule violation to you?                                                                   

Yes       No

If you answered yes to any of the above items, did the employee complete the return-to-duty process?           

Yes       No

NOTE:  If you answered yes to item 5, you MUST provide the previous employer's report. If you answered "yes" to item 6, you must also transmit the appropriate return-to-duty documentation

(e.g., SAP report(s), follow-up testing record).

SECTION 4: To be completed by previous Employer

Employee was Employed From:   _________________ 

Employee was Employed to:  _____________________

Reason For leaving:__________________________________________________________

Number of Accidents: ________________________________________________________    

Preventable: _______________________________________________________________

Was applicant's Drivers License ever suspended or revoked?                                                                                   

Yes       No

Was applicant's general conduct satisfactory?                                                                                                             

Yes       No

Was there a history of absenteeism or tardiness on this applicant?                                                                         

Yes       No

Did this applicant give adequate notice prior to leaving your employment?                                                         

Yes       No

It is a violation of our policy to release information other than that information provided here.                     

Yes       No

Federal law requires that DOT regulated employers respond in a timely manner to these requests. If a previous employer fails to respond to the request, it is the requirement of law that the potential or new employer submit documentation that a previous employer failed to respond to the CFR 49 Drug and Alcohol Request.

Employer representative completing form: __________________________________________

Signature: ________________________________________________________________

Date Completed: ___________

Telephone Number of Representative: ______________________

Title of Representative: _______________________________________________________

PLEASE SEND INFORMATION TO:  

CFR 49 Previous Employer Drug, Alcohol and Safety Request for information 9

Applicants that desire to drive in intrastate/interstate commerce must provide the following information on ALL EMPLOYERS during the previous three years. Additionally, you must provide the same information for all employers you HAVE DRIVEN A COMMERCIAL MOTOR VEHICLE for the seven years prior to the initial three years (total of ten years employment record for CDL drivers)

SECTION 1: To be completed by the applicant for submission to the previous employer. All fields are required.

Requesting Company Name:

Applicant Name:

Applicant Address:

Applicant Telephone:

Applicant Email Address:

Previous Employer:

Previous Employer Manager:

Previous Employer Address:        

Previous Employer Telephone:

Previous Employer FAX:  

Previous Employer Email:

Employed From:

Employed to: (enter current date if still employed):

Final hourly rate of Pay:

Reason for Leaving:

Were you subject to the Federal Motor Carrier Safety Regulations (FMCSRs) While employed by this employer?

Was the previous job position designated as a safety sensitive function in any DOT regulated mode, subject to alcohol and controlled substances testing requirements as required by 49 CFR Part 49?

SECTION 2: To be completed by the applicant. As required by CFR 49 Part 391.23(c), we are forwarding this inquiry on the above named person who has made application to the above referenced company for employment as a commercial vehicle operator or mechanic. We respectfully request that you reply to this inquiry to the extent that your company policy allows, regarding this applicant. The applicant has signed the attached liability release for your records.

RELEASE of INFORMATION Form-49 CFR Part 40 Drug and Alcohol Testing:  I hereby authorize the release of information from my Department of Transportation regulated drug and alcohol testing records by my previous employer listed in Section 1, to the employer listed in the header section. This release is in accordance with DOT Regulation 49 CFR Part 40,  Section 40.25. I understand that information to be released in Section 3 by my previous employer is limited to the following DOT regulated testing items.

Items to be released: Alcohol Tests with a result of 0.04 or higher, Verified positive drug tests, Refusals to be tested, Other violations of DOT agency drug and alcohol testing regulations, Information obtained from previous employers of a drug and alcohol rule violations, and Documentation, if any, of completion of the return-to-duty process following a rule violation.

SECTION 3: To be completed by the previous Employer and transmitted by mail, please fax or email to the new employer. Fax, Mail or Email with the information listed at top of the page.

Did the employee have alcohol tests with a drug result of 0.04 or higher?                                                               

Yes        No

Did the employee have verified positive drug results?                                                                                                   

Yes        No

Did the employee refuse to be tested?                                                                                                                               

Yes        No

Did the employee have other violations of DOT agency drug and alcohol testing rules?                                       

Yes        No

Did a previous employer report a drug or alcohol rule violation to you?                                                                   

Yes       No

If you answered yes to any of the above items, did the employee complete the return-to-duty process?           

Yes       No

NOTE:  If you answered yes to item 5, you MUST provide the previous employer's report. If you answered "yes" to item 6, you must also transmit the appropriate return-to-duty documentation

(e.g., SAP report(s), follow-up testing record).

SECTION 4: To be completed by previous Employer

Employee was Employed From:   _________________ 

Employee was Employed to:  _____________________

Reason For leaving:__________________________________________________________

Number of Accidents: ________________________________________________________    

Preventable: _______________________________________________________________

Was applicant's Drivers License ever suspended or revoked?                                                                                   

Yes       No

Was applicant's general conduct satisfactory?                                                                                                             

Yes       No

Was there a history of absenteeism or tardiness on this applicant?                                                                         

Yes       No

Did this applicant give adequate notice prior to leaving your employment?                                                         

Yes       No

It is a violation of our policy to release information other than that information provided here.                     

Yes       No

Federal law requires that DOT regulated employers respond in a timely manner to these requests. If a previous employer fails to respond to the request, it is the requirement of law that the potential or new employer submit documentation that a previous employer failed to respond to the CFR 49 Drug and Alcohol Request.

Employer representative completing form: __________________________________________

Signature: ________________________________________________________________

Date Completed: ___________

Telephone Number of Representative: ______________________

Title of Representative: _______________________________________________________

PLEASE SEND INFORMATION TO:   

CFR 49 Previous Employer Drug, Alcohol and Safety Request for information 10

Applicants that desire to drive in intrastate/interstate commerce must provide the following information on ALL EMPLOYERS during the previous three years. Additionally, you must provide the same information for all employers you HAVE DRIVEN A COMMERCIAL MOTOR VEHICLE for the seven years prior to the initial three years (total of ten years employment record for CDL drivers)

SECTION 1: To be completed by the applicant for submission to the previous employer. All fields are required.

Requesting Company Name:

Applicant Name:

Applicant Address:

Applicant Telephone:

Applicant Email Address:

Previous Employer:

Previous Employer Manager:

Previous Employer Address:        

Previous Employer Telephone:

Previous Employer FAX:  

Previous Employer Email:

Employed From:

Employed to: (enter current date if still employed):

Final hourly rate of Pay:

Reason for Leaving:

Were you subject to the Federal Motor Carrier Safety Regulations (FMCSRs) While employed by this employer?

Was the previous job position designated as a safety sensitive function in any DOT regulated mode, subject to alcohol and controlled substances testing requirements as required by 49 CFR Part 49?

SECTION 2: To be completed by the applicant. As required by CFR 49 Part 391.23(c), we are forwarding this inquiry on the above named person who has made application to the above referenced company for employment as a commercial vehicle operator or mechanic. We respectfully request that you reply to this inquiry to the extent that your company policy allows, regarding this applicant. The applicant has signed the attached liability release for your records.

RELEASE of INFORMATION Form-49 CFR Part 40 Drug and Alcohol Testing:  I hereby authorize the release of information from my Department of Transportation regulated drug and alcohol testing records by my previous employer listed in Section 1, to the employer listed in the header section. This release is in accordance with DOT Regulation 49 CFR Part 40,  Section 40.25. I understand that information to be released in Section 3 by my previous employer is limited to the following DOT regulated testing items.

Items to be released: Alcohol Tests with a result of 0.04 or higher, Verified positive drug tests, Refusals to be tested, Other violations of DOT agency drug and alcohol testing regulations, Information obtained from previous employers of a drug and alcohol rule violations, and Documentation, if any, of completion of the return-to-duty process following a rule violation.

SECTION 3: To be completed by the previous Employer and transmitted by mail, please fax or email to the new employer. Fax, Mail or Email with the information listed at top of the page.

Did the employee have alcohol tests with a drug result of 0.04 or higher?                                                               

Yes        No

Did the employee have verified positive drug results?                                                                                                   

Yes        No

Did the employee refuse to be tested?                                                                                                                               

Yes        No

Did the employee have other violations of DOT agency drug and alcohol testing rules?                                       

Yes        No

Did a previous employer report a drug or alcohol rule violation to you?                                                                   

Yes       No

If you answered yes to any of the above items, did the employee complete the return-to-duty process?           

Yes       No

NOTE:  If you answered yes to item 5, you MUST provide the previous employer's report. If you answered "yes" to item 6, you must also transmit the appropriate return-to-duty documentation

(e.g., SAP report(s), follow-up testing record).

SECTION 4: To be completed by previous Employer

Employee was Employed From:   _________________ 

Employee was Employed to:  _____________________

Reason For leaving:__________________________________________________________

Number of Accidents: ________________________________________________________    

Preventable: _______________________________________________________________

Was applicant's Drivers License ever suspended or revoked?                                                                                   

Yes       No

Was applicant's general conduct satisfactory?                                                                                                             

Yes       No

Was there a history of absenteeism or tardiness on this applicant?                                                                       

 Yes       No

Did this applicant give adequate notice prior to leaving your employment?                                                         

Yes       No

It is a violation of our policy to release information other than that information provided here.                     

Yes       No

Federal law requires that DOT regulated employers respond in a timely manner to these requests. If a previous employer fails to respond to the request, it is the requirement of law that the potential or new employer submit documentation that a previous employer failed to respond to the CFR 49 Drug and Alcohol Request.

Employer representative completing form: __________________________________________

Signature: ________________________________________________________________

Date Completed: ___________

Telephone Number of Representative: ______________________

Title of Representative: _______________________________________________________

PLEASE SEND INFORMATION TO:   

Criminal Background Check Authorization

APPLICANT AUTHORIZATION TO OBTAIN INVESTIGATIVE BACKGROUND REPORT In connection with my application for employment or promotion or other job change, I hereby instruct and authorize (the "Company") to obtain an INVESTIGATIVE CONSUMER REPORT on me that will include information as to my character, general reputation , personal characteristics and mode of living.

This report may reveal information about my work habits, including oral assessments of my job performance, experiences and abilities, along with reasons for termination of past employment. Such a report may be requested by the Company or on behalf of the Company. Further, I understand and agree that the Company and/or the below-named Consumer Reporting Agency may request information from various federal, state, and other agencies, including public and private sources which maintain records concerning my past activities relating to my driving record, credit history , criminal record, civil matters , previous employment , educational background and professional licensing, if any. This report will be ordered from the below-named Consumer Reporting Agency:

Social Security Number:

Date of Birth:

Eye Color:

Gender:

Hair Color:

Would you like to provide your ethnicity information at this time:

Race:

Height:

Weight:

The address you have lived at for the last seven years:

Current Address:

Years at Current Address:

Does this cover your last three years of residency? 

Second Address: 

Years at Second Address: 

Does this cover your last three years of residency? 

Third Address: 

Years at Third Address: 

Fourth Address: 

Years at Fourth Address: 

This is written notice from the Company that an investigative consumer report is being obtained from a consumer reporting agency (CRA) for employment purposes. The undersigned applicant hereby instructs, authorizes and requests any present or former employer , school , police department , financial institution , division of motor vehicles , or other persons or agencies having personal knowledge about the undersigned applicant to furnish the above-named Consumer Reporting Agency with any and all information in their possession regarding the undersigned applicant, in connection with an application for employment. The undersigned applicant hereby instructs, authorizes and requests that a photocopy of this authorization be accepted with the same authority as the original.

Under the federal Fair Credit Reporting Act (FCRA) and other applicable state law, you have certain rights with regard to consumer reports obtained for employment purposes including , upon request , disclosure of information on you in the reporting agency's file at the time of the request, including the identification of persons who have procured a consumer report concerning you, and reasonable opportunity to respond to any information in the report that is disputed by you. The FCRA, 15 U.S.C. 1681, is designed to promote accuracy, fairness, and privacy of information in the files of every "consumer reporting agency " (CRA). You can obtain a copy of any investigative consumer report obtained by Association Background Checks, Inc. Request for disclosure of the reporting agency's file should be made in writing within a 60 day time period to: .

If a consumer investigative report is obtained and an adverse decision is made affecting your employment, the Company will provide to you, before making the adverse decision, a copy of the investigative consumer report and a copy of the Federal Trade Commission Publication, A Summary of Your Rights Under the Fair Credit Reporting Act. The undersigned applicant hereby acknowledges that he/she (i) has read or has had read to him/her the above authorization and disclosures, (ii) has understood it, (iii) had the opportunity to consult with and discuss this form with his/her attorney prior to signing this document, and (iv) agrees to be fully bound by it.

EMPLOYER CERTIFICATION TO CONSUMER REPORTING AGENCY; By submitting this order to the above-referenced Consumer Reporting Agency, the undersigned Company and individual agent signing on behalf of the Company expressly certifies to the above-referenced Consumer Reporting Agency (i) that any reports procured relating hereto will be used for employment screening purposes only pursuant to FCRA Section 604(a)(3)(B) ; (ii) that prior to taking any adverse action, based in whole or in part upon said report(s), the Company will provide the applicant a copy of the report(s) and a copy of the publication, A Summary of Your Rights Under the Fair Credit Reporting Act; and (iii) that said report(s) will not be used in violation of any applicable Federal or State law or regulation including those specifically governing equal employment opportunity .

Employer Name:

Employer or Authorized Representative Signature: __________________________

I hereby Authorize: to run a criminal background check at this time.

 

MVR Authorization for Initial an Annual Review

ANNUAL AUTHORIZATION:

This form is for authorization to annually pull your MVR (motor vehicle record) for insurance purposes and review. This form exists in a secure environment, and the information is sent directly to the employer for review and storage in a secure environment.

Name: 

Driver License Number:

State of Issue:

DOL Eye Color:

Date of Birth:

Cellular Phone Number:

Type of record that will be requested can only be: EMPLOYMENT RECORD. Used to determine if a driver should be employed. Employers and their agents, prospective employers and their agents. 

INITIAL AUTHORIZATION:

This form is for authorization to initially pull your MVR (motor vehicle record) for insurance purposes and review. This form exists in a secure environment, and the information is sent directly to the employer for review and storage in a secure environment. This will only be pulled if you have failed to provide the correct MVR form in a timely fashion and your application indicates your experience and skills dictate would like to pursue the employment opportunity.

Name: 

Driver License Number:

State of Issue:

DOL Eye Color:

Date of Birth:

Cellular Phone Number:

Type of record that will be requested can only be: COMPLETE RECORD. Used to determine if a driver should be employed. Employers and their agents, prospective employers and their agents.

PSP Authorization Effective 2-1-2016

Company Name:

THE BELOW DISCLOSURE AND AUTHORIZATION LANGUAGE IS FOR MANDATORY USE BY ALL ACCOUNT HOLDERS. THIS IS AN IMPORTANT DISCLOSURE  REGARDING BACKGROUND REPORTS FROM THE PSP ONLINE SERVICE.

In connection with your application for employment with employer listed in the header above, 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).

Name of Applicant: 

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.

If you agree that the Prospective Employer may obtain such background reports, please read the following and sign below: I authorize the employer listed in the header above 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.

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

Date of Authorization: 

Name of Applicant:

I hereby authorize and its employees, authorized agents, and/or affiliates to obtain the information authorized above.

 

Certificate of Compliance

Name of license Holder:

MOTOR CARRIER INSTRUCTIONS: The requirements in Part 383 apply to every driver who operates in intrastate, interstate, or foreign commerce and operates a vehicle weighing 26,001 pounds or more, can transport more than 15 people, or transports hazardous materials that require placarding.

The requirements in Part 391 apply to every driver who operates in interstate commerce and operates a vehicle weighing 10,001 pounds or more, can transport more than 15 people, or transports hazardous materials that require placarding.

DRIVER REQUIREMENTS: Parts 383 and 391 of the Federal Motor Carrier Safety Regulations contain some requirements that you as a driver must comply with. These requirements are in effect as of July 1, 1987. They are as follows:

1) POSSESS ONLY ONE LICENSE:

You, as a commercial vehicle driver, may not possess more than one motor vehicle operator's license. If you have more than one license, keep the license from your state of residence and return the additional licenses to the states that issued them. DESTROYING a license does not close the record in the state that issued it; you must notify the state. If a duplicate licenses has been lost, stolen, or destroyed, close your record by notifying the state of issuance that you no longer want to be licensed by that state.

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 anytime 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 state must be in writing.

The following license is the only one I will possess:

Drivers License Number:

License Class:

Driver License State of Issue:

Date of License Expiration:

Name on Driver License:

 

This certifies that this application was completed by me and that all entries on it and information in it are true and complete to the best of my knowledge.

Leave this empty:

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Signature Certificate
Document name: APPLICATION | DOT
lock iconUnique Document ID: d8474e356dded720c7338b7a51c926a7eca2f970
Timestamp Audit
05/22/2018 18:43 PSTAPPLICATION | DOT Uploaded by Jeffery Brennan - jeff@beelinetours.com IP 209.50.8.111
11/19/2019 13:49 PST Document owner admin@beelinesafety.net has handed over this document to jeff@beelinetours.com 2019-11-19 13:49:04 - 199.15.219.90
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