GBC TRANSPORT APP

GBC TRANSPORT
Please put 10 years of employment history on application. Please furnish good phone numbers for the last 5 years.

Please sign release at the top part of the Safety Performance Sheet under the section labeled "Applicant".

We will be running both an MVR and a criminal check.
For further questions call 713-690-2886

DRIVER'S APPLICATION
Applying For

CompanyOwner Operator
AUTHORIZATION

Sign and date below.
I hereby authorize the Company upon execution of this consent form, to investigate the information contained in my employment application and any other background information (which may include but is not limited to my creditworthiness, credit standing, motor vehicle reports, credit capacity, criminal background, driving background, character, general reputation, personal characteristics, and mode of living), for the purpose of obtaining information relevant to my qualifications for employment, and unless prohibited by applicable law, my continued employment, retention, promotion, demotion, or any other employment purpose. I understand and agree that the Company or an outside consumer reporting agency may secure a consumer report or an investigative consumer report, as defined in the federal Fair Credit Reporting Act and any applicable state or local laws, from an outside consumer reporting agency. I hereby release employers, schools, health care providers and other persons from all liability in responding to inquiries and releasing information in connection with my application. 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 GBC Transport. 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 391.23 (d) and (e I have reviewed and understand all terms in the Disclosure section. 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 resend 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.

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

Clear
Date

MonthDayYear
Date

PERSONAL INFORMATION:

Please list all addresses for past 3 years.
Name

FIRST NAMELAST NAME
MI
STREET ADDRESS
NO.
CITY
STATE
ZIP
STREET ADDRESS
NO.
CITY
STATE
ZIP
Address

STREET ADDRESS

Street Address Line 2

CITYSTATE

ZIP
HOME PHONE
ALT. PHONE
SOCIAL SECURITY
DATE OF BIRTH

MonthDayYear
Date
LICENSE NO.
STATE
EXPIRATION DATE

MonthDayYear
Date
CLASS
Email
example@example.com

DRIVING EXPERIENCE
Type of equipment: Years of experience: Miles driven
ACCIDENT RECORD (Previous Three Years)
Accident deaths: Type of accident: Fatalities: Injuries:
TRAFFIC CONVICTIONS (Previous three years)
Location: Date: Charge: (Excluding parking violations)
LICENSE AND CRIMINAL BACKGROUND
A. Have you ever been denied a license, permit or privilege to operate a motor vehicle?

YESNO
B. Has any license, permit or privilege ever been suspended or revoked?

YESNO
IF THE ANSWER TO EITHER A OR B IS YES, GIVE DETAILS
Have you ever been arrested and/or convicted of a misdemeanor or felony?

YESNO
If yes, please explain fully. Conviction of a crime is not an automatic bar to employment, all circumstances will be considered.
EMERGENCY CONTACT
PHONE
RELATIONSHIP

FAIR CREDIT REPORTING ACT DISCLOSURE STATEMENT
In accordance with the provisions of Section 604 (b2A) of the Fair Credit Reporting Act, Public Law 91-508, as amended by the Consumer Credit Reporting Act of 1996 (Title II, Subtitle D, Chapter I, of Public Law 104-208), 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/contract purposes. These reports are required by Sections 382.413, 391.23, and 391.25, of the Federal Motor Carrier Safety Regulations.
Applicant's Signature

Clear
Date

MonthDayYear
Date
Print Name
Social Security Number

SAFETY PERFORMANCE HISTORY

I hereby authorize previous employers to release and forward the information requested by concerning my Alcohol and Controlled Substances testing records within the previous three (3) years from the date of application to (In compliance with 40.25 (g) and 391.23 (h) of the FMCSRs):

GBC Transport

5829 W Sam Houston Pkwy N Ste 201

PH 713-690-2886

FAX 832-408-7648
NAME
SSN
Email
SIGNATURE

Clear
DATE

MonthDayYear
Date

RELEASE OF CDL HOLDER'S REPORTED POSITIVE ALCOHOL OR CONTROLLED SUBSTANCE TEST RESULTS
authorize release of the CDL holder's reported positive alcohol or controlled substance test results reported under state law
Name
Address of CDL Holder
Driver License Number
State
Date of Birth

MonthDayYear
Date
Signature

Clear
Date

MonthDayYear
Date

DRIVER ALCOHOL AND DRUG STATEMENT

Sec. 40.25(j) As the employer, you must also ask the Driver whether he or she has tested positive, or refused to test, on any pre-employment drug and alcohol test administered by an employer to which the Driver applied for, but did not obtain, safety-sensitive transportation work covered by DOT agency drug and alcohol testing rules during the past two years. If the Driver admits that he or she had a positive test or a refusal to test, you must not use the Driver to perform safety-sensitive function for you, until and unless the Driver documents successful completion of the return-to-duty process (See 40.25(b5) and (e
Driver Name
Driver ID # (Last 4 of SSN)
The Driver is required by Sec. 40.25 to respond to the following question:
Have you tested positive, or refused to test, on any pre-employment drug or alcohol test administered by an employer to which you applied for, but did not obtain, safety-sensitive transportation work covered by DOT agency drug and alcohol testing rules during the past two years?

YesNo
Driver Signature

Clear
Date

MonthDayYear
Date

Drug and alcohol policy

To ensure a safe and productive work environment during company activities and to safeguard the company prohibits the use, sale, transfer and I or possession of drugs, inhalants or alcohol beverages or being impaired or under the influence of alcohol or any controlled substance on any Company premises, parking lot, work site, in any Company vehicle or while employees are conducting business.

Also, the Company strictly prohibits any visitor or subcontractor from being on Company premises or work sites while in a state of impairment due to drugs, inhalants or alcoholic beverages. Any individual found in violation will be refused entry onto, or removed from the Company's premises or work sites.

In addition to pre-employment drug/alcohol testing, the Company periodically conducts random drug/alcohol testing and reserves the right to test individual employees if drug/alcohol use is suspected. Refusal to take a requested drug/alcohol test or a positive result will be considered grounds for immediate termination of employment.

Excluded is the legitimate possession and proper use of medications specifically prescribed for the user by a licensed physician. Over-the-counter medications are also excluded, provided that such medications are used in strict compliance with the prescription and/or manufacturer's directions and that the use of the medication(s does not impair the employee's ability to perform his/her job.

Any employee who is taking any legal drug, prescription or over-the-counter medication that may impair their safety, performance or motor functions must advise his/her supervisor before reporting to work. Employees who must take prescription or over-the counter medications at work must keep such medication in their original containers or packaging which identify the drug, and if applicable the date of the prescription and the prescribing physician.

A company authorized representative may request to see the prescription in order to verify its legal use. Abuse of any prescribed or other drug is strictly prohibited and violation of this policy shall result in disciplinary action up to and including termination.
Print Name
Signature

Clear
Date

MonthDayYear
Date

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 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

("Prospective Employer"), Prospective

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 ttps://dataqs.fmcsa.do 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:

Iauthorize GBC Transport ("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.fmesa.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.

Iunderstand 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.
Date

MonthDayYear
Date
Signature

Clear
Name
NOTICE: This form is made available to monthly account holders by NIC 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.
Should be Empty:

GBC TRANSPORT

AUTHORIZATION

FAIR CREDIT REPORTING ACT DISCLOSURE STATEMENT