DRIVER S APPLICATION FOR EMPLOYMENT

Transcription

1 DRIVER S APPLICATION FOR EMPLOYMENT Applicant Name Date of Application (Print) Company: J7 TRUCKING, LLC Address: 5515 E Hwy 67 City: Alvarado TX PH: (817) FAX: (817) In compliance with Federal and State equal employment opportunity laws, qualified applicants are considered for all positions without regard to race, color, religion, sex, national origin, age, marital status, veteran status, non-job related disability, or any other protected group status. BE READ AND SIGNED BY APPLICANT I authorize you to make such investigations and inquiries of my personal, employment, financial or medical history and other related matters as may be necessary in arriving at an employment decision. (Generally, inquiries regarding medical history will be made only if and after a conditional offer of employment has been extended.)i hereby release employers, health care providers and other persons from all liability in responding to inquiries and releasing information in connection with my application. In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the company. I understand that information I provide regarding current and/or previous employers may be used, and those employer(s) will be contacted, for the purpose of investigating my safety performance history as required by 49 CFR (d) and (e). I understand that I have the right to: Review information provided by previous employers; Have errors in the information corrected by previous employers and for those previous employers to re-send the corrected information to the prospective employer; and Have a rebuttal statement attached to the alleged erroneous information, if the previous employer(s) and I cannot agree on the accuracy of the information. Signature Date FOR COMPANY USE PROCESS RECORD APPLICANT HIRED REJECTED EMPLOYED DEPARTMENT (If rejected, summary report of reasons should be placed in file) POINT EMPLOYED CLASSIFICATION SIGNATURE OF INTERVIEWING OFFICER TERMINATION OF EMPLOYMENT TERMINATED REJECTED DISMISSED VOLUNTARY QUIT OTHER TERMINATION REPORT PLACED IN FILE SUPERVISOR NOTES: 1 P a g

2 APPLICANT COMPLETE (Answer all questions please print) Position(s) Applied for Name Last First Middle Social Security No. List your Addresses of residency for the past 3 years. Current address Street City How Long? State Zip Code Phone yr. /mo. Previous Addresses How Long? Street City State & Zip Code yr. /mo. How Long? Street City State & Zip Code yr. /mo. How Long? Street City State & Zip Code yr. /mo. Do you have the legal right to work in the United States? Date of Birth / / (Required for Commercial Drivers) Have you worked for this company before? Can you provide proof of age? Where? Dates: From To Rate of Pay Position Held Reason for Leaving Are you now employed? if not, how long since leaving last employment? Who referred you? Rate of expected Have you ever been bonded? Name of bonding company Is there any reason you might be unable to perform the functions of the job for which you have applied [as described in the attached job description]? if yes, explain if you wish. EMPLOYMENT HISRY All driver applicants to drive in interstate commerce must provide the following information on all employers during the preceding 3 years: List complete mailing address, street number, city, state and zip code. Applicants to drive a commercial motor vehicle in interstate or interstate commerce shall also provide an additional 10 years information on those employers for whom the applicant operated such vehicle. (NOTE: List employers in reverse order starting with the most recent. Add another sheet as necessary.) WERE YOU SUBJECT THE FMCSRS+ WHILE EMPLOYED? YES NO 2 P a g

3 WAS YOUR JOB DESIGNATED AS A SAFETY-SENSITIVE FUNCTION IN ANY DOT-REGULATED MODE SUBJECT THE DRUG AND EMPLOYMENT HISRY (continued) WERE YOU SUBJECT THE FMCSRS+ WHILE EMPLOYED? YES NO WAS YOUR JOB DESIGNATED AS A SAFETY-SENSITIVE FUNCTION IN ANY DOT-REGULATED MODE SUBJECT THE DRUG AND WERE YOU SUBJECT THE FMCSRS+ WHILE EMPLOYED? YES NO WAS YOUR JOB DESIGNATED AS A SAFETY-SENSITIVE FUNCTION IN ANY DOT-REGULATED MODE SUBJECT THE DRUG AND WERE YOU SUBJECT THE FMCSRS+ WHILE EMPLOYED? YES NO WAS YOUR JOB DESIGNATED AS A SAFETY-SENSITIVE FUNCTION IN ANY DOT-REGULATED MODE SUBJECT THE DRUG AND WERE YOU SUBJECT THE FMCSRS+ WHILE EMPLOYED? YES NO WAS YOUR JOB DESIGNATED AS A SAFETY-SENSITIVE FUNCTION IN ANY DOT-REGULATED MODE SUBJECT THE DRUG AND WERE YOU SUBJECT THE FMCSRS+ WHILE EMPLOYED? YES NO WAS YOUR JOB DESIGNATED AS A SAFETY-SENSITIVE FUNCTION IN ANY DOT-REGULATED MODE SUBJECT THE DRUG AND WERE YOU SUBJECT THE FMCSRS+ WHILE EMPLOYED? YES NO WAS YOUR JOB DESIGNATED AS A SAFETY-SENSITIVE FUNCTION IN ANY DOT-REGULATED MODE SUBJECT THE DRUG AND 3 P a g

4 EMPLOYMENT HISRY (continued) WERE YOU SUBJECT THE FMCSRS+ WHILE EMPLOYED? YES NO WAS YOUR JOB DESIGNATED AS A SAFETY-SENSITIVE FUNCTION IN ANY DOT-REGULATED MODE SUBJECT THE DRUG AND WERE YOU SUBJECT THE FMCSRS+ WHILE EMPLOYED? YES NO WAS YOUR JOB DESIGNATED AS A SAFETY-SENSITIVE FUNCTION IN ANY DOT-REGULATED MODE SUBJECT THE DRUG AND WERE YOU SUBJECT THE FMCSRS+ WHILE EMPLOYED? YES NO WAS YOUR JOB DESIGNATED AS A SAFETY-SENSITIVE FUNCTION IN ANY DOT-REGULATED MODE SUBJECT THE DRUG AND WERE YOU SUBJECT THE FMCSRS+ WHILE EMPLOYED? YES NO WAS YOUR JOB DESIGNATED AS A SAFETY-SENSITIVE FUNCTION IN ANY DOT-REGULATED MODE SUBJECT THE DRUG AND WERE YOU SUBJECT THE FMCSRS+ WHILE EMPLOYED? YES NO WAS YOUR JOB DESIGNATED AS A SAFETY-SENSITIVE FUNCTION IN ANY DOT-REGULATED MODE SUBJECT THE DRUG AND WERE YOU SUBJECT THE FMCSRS+ WHILE EMPLOYED? YES NO WAS YOUR JOB DESIGNATED AS A SAFETY-SENSITIVE FUNCTION IN ANY DOT-REGULATED MODE SUBJECT THE DRUG AND 4 P a g

5 ACCIDENT RECORD FOR PAST 3 YEARS OR MORE (ATTACH SHEET IF MORE SPACE NEEDED) IF NONE, WRITE NONE S NATURE OF ACCIDENT (Head-on, rear-end, upset, etc.) FATALITIES INJURIES HAZARDOUS MATERIAL SPILL LAST ACCIDENT NEXT PREVIOUS NEXT PREVIOUS TRAFFIC CONVICTIONS AND FORFEITUTRES FOR THE PAST 3 YEARS (OTHER THAN PARKING VIOLATIONS) IF NONE, WRITE NONE LOCATION CHARGE PENALTY Driver Licenses or Permits held In the past 3years (ATTACH SHEET IF MORE SPACE NEEDE) EXPERIENCE AND QUALIFICATIONS-DRIVER STATE LICENSE NO. CLASS ENDORSMENT (S) EXPIRATION A. Have you ever been denied a license, permit or privilege to operate a motor vehicle? YES NO B. Has any license, permit or privilege ever been suspended or revoked? YES NO IF THE ANSWER EITHER A OR B IS YES, GIVE DETAILS DRIVING EXPERIENCE CHECK YES OR NO CLASS EQUIPEMENT CIRCLE TYPE OF EQUIPMENT STRAIGHT TRUCK YES NO (VAN,TANK,FLAT,DUMP,RE FER) TRACR AND SEMI-TRAILER YES NO (VAN,TANK,FLAT,DUMP,RE FER) TRACR TWO TRAILERS YES NO (VAN,TANK,FLAT,DUMP,RE FER) TRACR THREE TRAILES YES NO (VAN,TANK,FLAT,DUMP,RE FER) MORCOACH SCHOOL BUS YES NO More than 8 passengers MORCOACH SCHOOL BUS YES NO More than 15 passengers OTHER S (M/Y) (M/Y) APPROX. NO. OF MILES (TAL) LIST STATES OPERATED IN FOR THE LAST FIVE YEARS: SHOW SPECIAL COURSES OR TRAINING THAT WILL HELP YOU AS A DRIVER: WHICH SAFE DRIVING AWARDS DO YOU HOLD AND FRON WHOM? EXPERIENCE AND QUALIFICATIONS OTHER SHOW ANY TRUCKING, TRANSPORTATION OR OTHER EXPERIENCE THAT MAY HELP IN YOUR WORK FOR THIS COMPANY LIST COURSES AND TRAINING OTHER THAN SHOWN ELSEWHERE IN THIS APPLICATION LIST SPECIAL EQUIPMENT OR TECHNICAL MATERIALS YOU CAN WORK WITH (OTHER THAN THOSE ALREADY SHOWN) EDUCATION CIRCLE HIGHEST GRADES COMPLETED: HIGH SCHOOLS: COLLEGE: LAST SCHOOL ATTENDED () BE READ AND SIGNED BY APPLICANT 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. Signature: Date: / / 5 P a g

6 DRIVER STATEMENT OF ON-DUTY HOURS (For Newly Hired Drivers) INSTRUCTIONS: Motor carriers, when using a driver for the first time, must obtain from the driver a signed statement giving the total time on-duty during The immediately preceding 7 days and the time at which the driver was last relieved from duty prior to beginning work for the carrier, as required by section (j) (2) of the Federal Motor Carrier Safety Regulations. NOTE: Hours for any work during the preceding 7 days, including any compensated work for a non-motor carrier, must be recorded on this form. This form should be completed on the day driver is scheduled to begin driving a commercial motor vehicle, and must be kept on file for at least 6 months. Driver Name (print) Employee ID No.: DAY 1 (yesterday) HOURS WORKED TAL HOURS I hereby certify that the information given above is correct to the best of my knowledge and belief, And that I was last relieved from work at: A.M. P.M. On / / Time Day Month Year / / Driver s Signature Date DRIVER CERTIFICATION FOR OTHER COMPENSATED WORK INSTRUCTIONS: When employed by a motor carrier, a driver must report to the carrier all on-duty time including time working for other employers. The definition of on-duty time found in section paragraphs (8) and (9) of the federal Motor Carrier Safety Regulations includes time performing any other work in the capacity of, or in the employment or service of, a common, contract or private motor carrier, and performing any compensated work for any non-motor carrier entity. (Check one) Are you currently working for another employer? Yes No At this time do you intend to work for another employer while still employed by this company? Yes No I hereby certify that the information given above is true and I understand that once I become employed with this company, if I begin working for any additional employer(s) for compensation that I must inform this company immediately of such employment activity. Driver s Signature Date Witness: Company Representative Date 6 P a g

7 OFF DUTY AUTHORIZATION The Department of Transportation has issued an interpretation to 49 CFR of the Hours of Service Regulations to allow meal stops and other routine coffee breaks or rest stops to be logged as Off Duty provided: (I) that the driver has been relieved of all duty and responsibility for the care and custody of the equipment and its cargo, (II) that the duration of the driver s relief is of sufficient duration to ensure that fatigue is reduced, (III) and that during the relief period the driver is at liberty to pursue activities of his own choosing and to leave the premises on which the vehicle is parked. By authority of this letter you are relieved from duty and all responsibility for vehicle and cargo after is properly parked and stationed in full accordance with federal, state and local regulations. However, this may be done only under all the following circumstances: 1. Two coffee breaks of fifteen minutes duration and two meal stops of one hour durations in each 11 hour driving period. Any time in excess of this must be logged as on-duty not driving. 2. In the case of an accident and/or breakdown you are relieved from duty and responsibility for the vehicle and cargo only after the vehicle is repaired or you have obtained assistance and are no longer required to remain in attendance and are no longer required to remain in attendance with the vehicle. 3. Your vehicle must be parked in a safe manner so as to prevent obstruction of traffic and theft or damage to your vehicle. 4. You are free to pursue activities of your own choosing and to leave the premises where the vehicle is parked as long as your liability to safely operate your vehicle is not impaired (DOT Regulation 49 CFR Part 392.5). You are not allowed to record meal and routine stops as Off Duty if your vehicle is laden with hazardous materials. When hazard materials are on your vehicle, you must comply with the attendance and surveillance requirements of DOT Regulation 49 CFR Part 397. Print Applicant Name Applicant Signature Date Company Representative Signature Date 7 P a g

8 MOR VEHICLE DRIVER S CERTIFICATION OF COMPLIANCE WITH DRIVER LICENSE REQUIREMENTS MOR 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 required placarding. DRIVER REQUIREMENTS: 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 (b) (2) and of 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 requires that any time you are convicted of violating a state or local traffic law (other than parking), you must report it a within 30 days to: 1) your employer motor carrier, and 2) the state that issue license (if the violation occurs in the state other than the issued your license). The notification to both the employer and state must be in writing. 3) CDL DOMICILE REQUIREMENTS: Section (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 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 possess: Driver s license No. State Exp. Date / / DRIVER CERTIFICATION: I certify that I have read and understood the above requirements. Driver s Name (printed): Driver s Signature: Date: / / NOTES: 8 P a g

9 MOR VEHICLE DRIVER S Certification of Violations/Annual Review of Driving Record MOR CARRIER INSTRUCTIONS: Each motor carrier shall at least once every 12 months, require each driver it employs to prepare and furnish it with a list of all violations of motor vehicle traffic laws and ordinances (other than violations involving only parking) of which the driver has been convicted, or on account of which he/she has forfeited bond or collateral during the preceding 12 months (Section ) Drivers who have provided information required by Section need not to repeat that information on this form. DRIVER REQUIREMENTS: Each driver shall furnish the list as required by the motor carrier above. If the driver has not been convicted of, or forfeited bond or collateral on account of any violation which must be listed, he/she shall so certify (Section ). COMPLETED BY DRIVER CERTIFICATION OF VIOLATIONS Name of Driver: (print) ID Number Date of Employment Home Terminal (City and State) Driver s License Number State Expiration Date I certify that the following is true and complete list of traffic violations required to be listed (other than those I have provided under Part 383) for which I have been convicted or forfeited bond or collateral during the past 12 months. (If you have no violations, check the following box - None.) OFFENSE LOCATION TYPE OF VEHICLE OPERATED If no violations are listed above, I certify that I have not been convicted or forfeited bond or collateral on account of any violation (other than those I have provided under Part 383) required to be listed during the past 12 months. Date Driver s Signature COMPLETED BY MOR CARRIER ANNUAL REVIEW OF DRIVING RECORD MOR CARRIER INSTRUCTIONS: Review the Certification of Violations listed above and other information described in Section of the Federal Motor Carrier Safety Regulations. Complete the information below. I have hereby reviewed the driving record of the above named driver in accordance with Section and find that he/she (check one): Meets minimum requirements for safe driving Is disqualified to drive a motor vehicle pursuant to Section Does not adequately meet satisfactory safe driving performance Action taken with driver: Reviewed by: Signature Printed Name Date Title Motor Carrier Name Motor Carrier Address MAINTAIN THIS DOCUMENT IN THE DRIVER S QUALIFICATION FILE. THIS DOCUMENT MAY BE PURGED AFTER 3 YEAR OF EXECUSION. 9 P a g

10 REQUEST FOR CHECK OF DRIVING RECORD NOTE MOR CARRIER: SEE BACK SIDE FOR STATE THAT ACCEPT THIS FORM. I hereby authorize you to release the following information to: J7 TRUCKING, LLC for purposes of investigation as required by Section and of the Federal Motor Carrier Safety Regulations. You are released from any and all liability which may result from furnishing such information. (Applicant s Signature) (Date) In accordance with the provisions of Sections 604 and 607 of the Fair Credit Reporting Act, Public Law , as amended by the Consumer Credit Reporting Act of 1996 (Title II, Subtitle D, Chapter 1, of Public Law ), I hereby the following: 1. The consumer (applicant) has authorized in writing the procurement of this report; 2. The consumer (applicant) has been informed in a separate written disclosure that a consumer report may be obtain for employment purposes; 3. The information requested below will be used for a permissible purposes (i.e., information for employment Purposes; 4. The information being obtained will not be used in violation of any federal or state equal opportunity law or Regulation; and 5. Before taking an adverse action based in whole or in part on the report the consumer (applicant) will receive a copy of the requested report and the summery of consumer rights as provided with the report by the consumer reporting agency. I also hereby certify that this report request and the above applicant s release notice meet the definition of permissible uses of state motor vehicle records under the provisions of the Driver Privacy Protection Act of 1994 (Public Law , Title XXX, Section (a). (Signature of Requester) (Date) : DEAR SIR/MADAM: The following named person has made application with our company for the position of. In accordance with Section , Federal Department of Transportation Regulations, please Please furnish the undersigned with the applicant s driving record for the past 3 years. The following named person is employed with our company in the position of In accordance with Section , Federal Department of Transportation Regulations, please furnish the undersigned with the employee s driving record for the past year. OF APPLICANT/DRIVER (Street Number) (City) (State) (Zip Code) FORMER (Street Number) (City) (State) (Zip Code) OF BIRTH: / / SSN: / / LICENSE NO. (Name of Company) (Address) REQUESTED BY (Type Name) (City) (State) (Zip Code) (Signature) (Title) 10 P a g

11 Fair Credit Reporting Act Disclosure Statement_ In accordance with the provisions of Section 604 (b) (2) (A) of the Fair Credit Reporting Act, Public Law , as amended by the Consumer Credit Reporting Act of 1996 (Title II, Subtitle D, Chapter I. of Public Law ), you are being informed that reports verifying your previous employment, previous drug and alcohol test results and your driving record may be obtained on you for employment purpose. These reports are required by Section , , and of the Federal Motor Carrier Safety Regulations. (Print Name) (SSN (Applicant s Signature) (Date) 11 P a g

12 CONSUMER REPORT AND INVESTIGATIVE CONSUMER REPORT DISCLOSURE (FOR EMPLOYMENT PURPOSES) In connection with your employment or application for employment (including contract for services) and in accordance with the applicable laws, J7 TRUCKING may obtain or assemble consumer reports and/or investigative consumer reports (collectively, Reports ) which may include information about your related: previous employment (including employers, dates of employment, salary information, reasons for termination, etc.), accident history, academic history, verification of references and other information supplied by applicant, professional credentials, drug/alcohol use in violation of law and/or public policy, driving record, worker s information about your character, general reputation, personal characteristics, and mode of living (collectively references, personal interviews and other information suppliers (collectively Suppliers ). Upon providing proper identification and complying with any applicable legal requirements, you have the right to request the nature and substance of all information in J7 TRUCKING s files pertaining to you at the time of your request, including but not limited to: (I) whether any Reports have been provided by J7 TRUCKING to other parties; (II) identification of any Suppliers utilized by J7 TRUCKING in compiling such Reports; and (III) identification of any recipients of Reports furnish by J7 TRUCKING within the 2 year period preceding your request. J7 TRUCKING may be contacted by mail at 5515 E Hwy 67, Alvarado, TX or by phone at (817) AUTHORIZATION FOR RELEASE OF INFORMATION (FOR EMPLOYMENT PURPOSES) I hereby authorize J7 TRUCKING to receive information for the purpose of making a determination as to my eligibility for employment, promotion, retention or other lawful purpose. If hired or contracted, I authorize J7 TRUCKING to retain this document on file to act as ongoing authorization for the procurement and possession of Reports at any time during my employment or contract period. I fully release J7 TRUCKING and suppliers from all claims of damages related to the investigation of my background and provision of information as set forth in this disclosure and authorization. By signing below, I certify that (I) all information provided herein is complete and accurate; (II) I have read and fully understand this disclosure and authorization for release; (III) prior to signing I was given an opportunity to ask questions and to have those questions answered to my satisfaction ;( IV) I execute this authorization voluntarily and with the knowledge that the information obtain pursuant to this authorization could affect my eligibility for employment, promotion, retention or other lawful purpose; (V) I understand I may review this document with legal counsel prior to signing; and (VI) facsimile or photographic copies of this authorization are as valid as an original. Print Applicant Name: Social Security #: / / Applicant Signature: Date: / / 12 P a g

13 DISCLOSURE AND AUTHORIZATION FOR RELEASE OF INFORMATION FOR EMPLOYMENT PURPOSES 49-CFR PART , DOT DRUG & ALCOHOL TESTING In accordance with DOT Regulations 49 CFR Part , I hereby authorize release of my DOT regulated drug and alcohol testing records by the DOT regulated employer(s) listed below to J7 TRUCKING. I understand the information/documents released pursuant to this authorization are limited to the following DOT- Regulated testing items, including pre-employment testing results, occurring during the previous 3 years: (I) alcohol tests with a result of 0.04 or higher; (II) verified positive drug tests; (III) refusals to be tested (including adulterated and substituted tests); (IV) other violations of DOT drug and alcohol testing regulations (i.e., violations of 49 CFR 382 Subpart B); (V) Information obtained from previous employers of a drug and alcohol rule violation; and (VI) any documentation of completion of the returned of the return-to-duty process following a rule violation. If any company listed below furnishes J7 TRUCKING with information to J7 TRUCKING with information concerning items (I) through (VI) above, I also authorize such company to furnish the following information to J7 TRUCKING, if applicable; (I) dates of my negative drug and/or alcohol tests and/or tests and/or test with results below 0.04 during the previous 3 years; and (II) the names and phone number of any substance abuse professional who evaluated me during the previous 3 years. List all DOT- regulated employers you have applied with and/or worked for in a safety-sensitive function during the previous 3 years. If necessary, attach additional pages, including the date, your name, social security number and signature. Previous DOT Regulated Employer City State Phone Number ( ) - ( ) - ( ) - ( ) - ( ) - By signing below, I certify that (I) all information provided herein is complete and accurate; (II) I have and fully understand this disclosure and authorization for release; (III) prior to signing I was given an opportunity to ask questions and to have those answered to my satisfaction; (IV) I execute this authorization voluntarily and with the knowledge that the information obtained pursuant to this authorization could affect my eligibility for employment, promotion, retention, or other lawful purpose; (V) I understand I may review this document with legal counsel prior to signing; and (VI) facsimile or photographic copies of this authorization are as valid as an original. Print Applicant Name: Social Security #: Applicant Signature: Date: / / 13 P a g

14 IMPORTANT NOTICE REGARDING BACKGROUND REPORTS PSP Online Service 1. In connection with your application for employment with J7 TRUCKING, LLC ( Prospective Employer ), it may obtain one or More reports regarding your driving and safety inspections history from the Federal Motor Safety Administration (FMCSA). When the application 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 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 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 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 indentification, request a free copy of the report and may dispute with the FMCSA the accuracy or completeness of any information 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 Reporting Act. The Prospective Employer cannot obtain background reports from FMCSA unless you consent in writing. If you agree that the prospective Employer may obtain such background reports, please read the following and sign below: 2. I authorize J7 TRUCKING, LLC ( 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 consenting to release of safety performance information including crash data from the previous (5) years and inspection history from the previous (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. 3. 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 If I am challenging crash or inspection information report by a State, FMCSA cannot change or correct this data. I understand my request will be forwarded by the DataQs system and to the appropriate State for adjustation. 4. Please note: Any crash or inspection in which you are 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 inspection, with or without violations, appear on the PSP report. State Citations associated with FMCSA, violations that have been adjudicated by a court of law will also appear and remain, on a PSP report. I have read the above Notice Regarding Background Reports provided to me by Prospective Employer and I understand that if I sign this consent form, 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. Name (please Print) (Date) (Signature) 14 P a g