Education/Type:

Please provide your complete Employment History for the last 10 years. If you drove a commercial vehicle at any time in the 7 years before the last 10 years, please detail that employment information as well.

If the answer to any of the questions below is Yes, please provide additional details in the box below.

I, the applicant, certify that the entries and information set forth in this Application are true and complete to the best of my knowledge. I understand that deliberately entering false information will result in the withdrawal of any offer/transfer.

PLEASE READ CAREFULLY BEFORE SIGNING. Initial where indicated and sign the reading all certifications and notices contained therein.

1. I certify that the information contained in this application for employment at the Company is correct and complete. I understand that any false or misleading statements or omissions made in this application or interview(s), whenever discovered are grounds for disqualification from further consideration or for dismissal from employment, regardless of how discovered.
   
   
2. I understand that if I am offered employment at the Company it is at-will and can be terminated at any time and for any reason with or without advance notice by myself or the company.
   
   
3. I understand and agree that only the Company has any authority to enter into any agreement to employ me for any specified period of time or to modify the terms and conditions of my employment. I agree that such an agreement must be in writing and signed by the Executive Director, and I will not rely upon any other representations regardless of the source.
   
   
4. I understand and agree that the Company may make a fully complete investigation of my personal employment history, and authorize any former employer, person, firm, corporation, school, government agency, or other entity to provide the Company with any information (including fact or opinion) they may have regarding me. In consideration of the Company’s review of this application, I release the Company and all providers of any information from any liability, which may arise as a result of furnishing or receiving this information. I understand and agree any employment offer or continued employment shall authorize the Company to provide truthful information (fact or opinion) regarding my employment to any potential or future employer and release and waive any claims against the company for truthfully communicating any such information to be potential or future employer.
   
   
5. I understand and agree that I may be required to submit to drug testing and complete a medical examination as part of my application for employment. I also understand and agree that I may be required to submit to additional medical examinations during my employment with the Company, provided that such examination is job-related and consistent with business necessity. I consent to such testing and authorize the physician conducting the examination and any laboratory testing, any specimen obtained by the physician or collection site to disclose the results of the examination and the laboratory test to the Company if requested. The Company will keep such results confidential and disclose the results only to persons who need to know where required by law. Also, I agree to fully cooperate and provide the company with any additional consent(s) and/or release(s) as required by the Company to investigate my employment application. 
   
   
6. I agree that the Company may investigate and consider any criminal conviction record that I may have after it makes a conditional offer of employment. The Company may withdraw a conditional employment offer if I have a criminal conviction record which bears a rational relationship to the duties and responsibilities of the position for which I am applying. 
   
   
7. I understand and agree that if offered employment by the Company I may be required to disclose military service information in accordance with the law, and that any such employment offer shall be dependent upon the receipt of satisfactory military record as determined by the Company.
   
   
8. If hired, I agree not to disclose or use confidential information belonging to prior employees and that I will inform the Company of any agreements that would limit my ability to work for the Company.

Disclosure and Authorization to Obtain Consumer Reports and Driving Performance History

In order to evaluate you for hiring, promotion, reassignment, transfer, retention in employment, or other employment-related purposes, the Company may decide to obtain a consumer report bearing on your creditworthiness, credit standing, credit capacity, character, general reputation, personal characteristics, or mode of living. However, no consumer report will be obtained by the Company for employment purposes without your prior written authorization.  I hereby acknowledge that the Company has disclosed, in writing, that it may obtain a consumer report bearing on my credit worthiness, credit standing, credit capacity, character, general reputation, personal characteristics, or mode of living for employment purposes. I hereby authorize the Company and its representatives and agents to obtain a consumer report bearing on my credit worthiness, credit standing, credit capacity, character, general reputation, personal characteristics or mode of living. 

I hereby acknowledge and consent to the Company to obtain and review reports of driver history from states in which a license has been held in accordance with, but not limited to, 48 CFR Part 391.  This consent shall be considered continuing, permitting for additional driver history inquiries as deemed necessary by the Company for the entire length of my employment with the Company. 

Previous Employer Inquiries and Investigations

As required by 391.23, we will make investigative inquiries to previous DOT-regulated employers related to your employment history, drug and alcohol testing results, and accident history.  We will use this information in our hiring decision.  Pursuant to 391.23, you have the following rights with regard to responses received in these areas from previous DOT-regulated employers:

1. The right to review information provided by previous DOT-regulated employers:
2. The right to have errors in the information corrected by the previous employer; and for that previous employer to re-send the corrected information to the prospective employer;
3. The right to have a rebuttal statement attached to the alleged erroneous information, if you and the previous employer cannot agree on the accuracy of the information.

If you wish to review previous DOT-regulated employer information received in response to required inquiries, you must submit a written request to the prospective employer no later than 30 days after being employed or being notified of denial of employment.  After making such written request, any information received will be provided to you within five days, unless no such information has been provided in response to required inquiries.  For information on procedures to rebut information provided by previous DOT-regulated employers, see Title 49 of the Coded Federal Regulations (CFR), Part 391.23(j). 

 

I hereby acknowledge and certify that I have read and understood these Authorizations and Notifications in this section of this Application for Employment.