MAGS Trucking Job Application

Application for Employment

MAGS Trucking, Inc.
Full Name*

First NameMiddle NameLast Name
Email Address*
Mobile Phone*

Area CodePhone Number
Home Phone

Area CodePhone Number
Current Address*

Street Address

Street Address Line 2

CityState

Zip Code
Please list any other addresses where you have resided within the last 3 years:*
Date of Birth*

MonthDayYear
Date
Driver License Number*
DL State Issued*

Street Address

Street Address Line 2

CityState

Zip Code
DL Expiration*

MonthDayYear
Date
Additional Information
Social Security Number*
Have you ever been convicted of a felony?*

YesNo
Please explain.
Have you ever served in the military?*

YesNo
What branch of the military?
What type of discharge did you receive?
What dates did you serve?
Are you receiving Military Disability?
Emergency Contact
In case of emergency, notify:*

First NameLast Name
Emergency Contact Phone*

Area CodePhone Number
Relationship*

Employment History

List your employment history for the past 10 years. Account for all of the time, including periods of unemployment. Provide a source to verity any self-employment.

	Employer	Phone	Position	Dates Employed	Reason for Leaving	FMCSR?	Safety Sensitive?
1
2
3
4
5
6
7
8

May we contact your current employer?*

YesNo
If no, please list someone familiar with your work that we can contact:
Applicant Certification

I understand and agree that my completion of this Employment application and MAGS Trucking, Inc acceptance of it does not obligate MAGS Trucking, Inc to take any further action. I understand and agree that any employment relationship established between either MAGS Trucking, Inc or I may terminate my employment at will. I certify that this application was completed by me, and I have answered truthfully and completely all questions on this application and in any interviews to the best of my knowledge.
Date*

MonthDayYear
Date
Signature*

Clear

THE BELOW DISCLOSURE AND AUTHORIZATION LANGUAGE IS FOR MANDATORY USE BY ALL ACCOUNT HOLDERS

IMPORTANT DISCLOSURE

REGARDING BACKGROUND REPORTS FROM THE PSP Online Service

In connection with your application for employment with MAGS Trucking, Inc ("Prospective Employer"), Prospective Employer, its employees , agents or contractors may obtain one or more reports regarding your driving, and safety inspection history from the Federal Motor Carrier Safety Administration (FMCSA).

When the application for employment is submitted in person, if the Prospective Employer uses any information it obtains from FMCSA in a decision to not hire you or to make any other adverse employment decision regarding you, the Prospective Employer will provide you with a copy of the report upon which its decision was based and a written summary of your rights under the Fair Credit Reporting Act before taking any final adverse action. If any final adverse action is taken against you based upon your driving history or safety report, the Prospective Employer will notify you that the action has been taken and that the action was based in part or in whole on this repo1i.

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 repo1i. If you request a copy of a driver record from the Prospective Employer who procured the report, then, within 3 business days of receiving your request, together with proper identification, the Prospective Employer must send or provide to you a copy of your report and a summary of your rights under the Fair Credit Reporting Act.

Neither the Prospective Employer nor the FMCSA contractor supplying the crash and safety information has the capability to correct any safety data that appears to be incorrect. You may challenge the accuracy of the data by submitting a request to https://dataqs.fmcsa.dot.gov. If you challenge crash or inspection information reported by a State, FMCSA cannot change or correct this data. Your request will be forwarded by the DataQs system to the appropriate State for adjudication.

Any crash or inspection in which you were involved will display on your PSP report. Since the PSP report does not report , or assign, or imply fault, it will include all Commercial Motor Vehicle (CMV) crashes where you were a driver or co-driver and where those crashes were reported to FMCSA, regardless of fault. Similarly, all inspections, with or without violations, appear on the PSP report. State citations associated with Federal Motor Carrier Safety Regulations (FMCSR) violations that have been adjudicated by a court of law will also appear, and remain, on a PSP report.

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

AUTHORIZATION

If you agree that the Prospective Employer may obtain such background reports, please read the following and sign below:

I authorize MAGS Trucking, Inc (."Prospective Employer") to access the FMCSA Pre-Employment Screening Program (PSP) system to seek information regarding my commercial driving safety record and information regarding my safety inspection history. I understand that I am authorizing the release of safety performance information including crash data from the previous five (5) years and inspection history from the previous three (3) years. I understand and acknowledge that this release of information may assist the Prospective Employer to make a determination regarding my suitability as an employee .

I further understand that neither the Prospective Employer nor the FMCSA contractor supplying the crash and safety information has the capability to correct any safety data that appears to be incorrect. I understand I may challenge the accuracy of the data by submitting a request to https://dataqs.fmcsa.dot.gov. !fl 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 repo1t.

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.
Date*

MonthDayYear
Date
Name*

First NameLast Name
Signature*

Clear
NOTICE: This form is made available to monthly account holders by NTC on behalf of the U.S. Department of Transportation, Federal Motor Carrier Safety Administration (FMCSA). Account holders are required by federal law to obtain an Applicant's written or electronic consent prior to accessing the Applicant's PSP report. Further, account holders are required by FMCSA to use the language contained in this Disclosure and Authorization form to obtain an Applicant's consent. The language must be used in whole, exactly as provided. Further, the language on this form must exist as one stand-alone document. The language may NOT be included with other consent forms or any other language.

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

LAST UPDATED 12/22/2015

DRIVER'S RIGHTS PERTAINING TO RELEASE OF DRIVER INFORMATION UNDER REGULATION§ 391.23

Motor Carrier have the responsibility to make the following investigations and inquiries with respect to each driver employed, other than a person who has been regularly employed driver of the motor carrier for a continuous period which began before January 1,1971.
- (a) (I) An inquiry into the driver's driving record during the preceding three years to the appropriate agency of every State in which the driver held a motor vehicle operator's license or permit during those three years; and
- (a) (2) An investigation of the driver's employment record during the preceding three years.
- (b) A copy of the driver record(s) obtained in response to the inquiry or inquiries to each State driver record agency as required must be placed in the Driver Qualification File within 30 days of the date of the driver's reemployment begins and be retained in compliance with 391.51
- (c) Replies to the investigations of the driver's safety performance history must be placed in the Driver Investigation History File with in 30 days of the date the driver's employement begins.
  This goes into effect after October 29, 2004
- (d) Prospective motor carrier must investigate the information from all previous employers of the applicant that employed the driver to operate a CMV within the previous three years. This information must cover general driver identification and employment verification infonnation, data elements as specified in 390.15 for accident involving the driver that occurred in the three year period preceding the date of the employment application and any accidents the previous employer may wish to provide.
- (e) Prospective motor carrier must invest igate the information from all previous DOT regulated employers that employed the driver within the previous three years from the date of the employment application in a safety-sensitive function that required alcohol and controlled substance testing specified by 49 CFR Part 40.
Drivers have the following rights:
1. The right to review information provided by previous employers .
2. The right to have etTors in the information corrected by the previous employer and for that previous employer to re-send the corrected information to the prospective employer.
3. The right to have a rebuttal statement attached to the alleged erroneous information, if the previous employer and the driver cannot agree on the accuracy of the infmmation.
Drivers who wish to review previous employer-provided investigative information must submit a written request to the prospective employer when applying or as late at 30 days after employed to being notified of denial employment. The prospective employer must provide this information to the applicant within 5 business days of receiving the written request. If the driver has not arranged to pick up or receive the requested records with in 30 days of the prospective employer making them available, the prospective motor carrier may consider the driver to have waived his/her request to review the records.

Drivers wishing to request correction of erroneous info1mation in records must send the request for correction to the previous employer that provided the records. After October 29, 2004, the previous employer must either correct and forward the information to the prospective motor carrier employer or notify the driver within 15 days of receiving the driver's request to correct the data that it does not agree to the correct data. Driver's wishing to rebut infmmation in records must send the rebu ttal to the previous employer with instruction to include the rebuttal in the driver's Safety Perfonnance History.

I acknowledge that I have read and understand the contents of this document.
Driver Signature*

Clear
Date*

MonthDayYear
Date
Driver Full Name*

First NameLast Name

Should be Empty:

Application for Employment

Additional Information

Emergency Contact

Driving Record

Employment History