I authorize AMERICAN VAN LINES, 1351 NW 22ND ST, POMPANO BEACH, FL 33069 and its authorized agents to make investigations (including contacting current and prior employers) into my personal, employment, financial, medical history, and other related matters as may be necessary in arriving at an employment decision. 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.

In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I also understand that I am required to abide by all rules and regulations of the Company.

I understand that the information I provide regarding my current and/or prior 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. I understand that I have the right to:

• Review information provided by current/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 I completed this application, and that all entries on it and information in it are true and complete to the best of my knowledge. Note: A motor carrier may require a Driver to provide more information than that required by the Federal Motor Carrier Safety Regulations.

MOTOR CARRIER INSTRUCTIONS:  The requirements in Part 383 apply to every driver who operated in Intrastate, Interstate, or foreign commerce and operates a vehicle weighing or rated at 26,001 lbs. or more, can transport more than 15 people, or transports hazardous materials which require placarding.

The requirements in Part 391 apply to every driver who operates in Interstate commerce and operates a vehicle weighing or rated at 10,001 lbs. or more, can transport more than 15 people (or more than 8 people when there is direct compensation), or transports hazardous materials which require placarding.

DRIVER REQUIREMENTS: Parts 382 and 291 of the FMCSR’s 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 391.15(b)(2) and 383.33 of the FMCSR’s require that you notify your employer the NEXT BUSINESS DAY of any revocation, suspension, cancellation or disqualification of your driver’s license or driving privilege.  In addition, Section 383.31 requires that at any time you are convicted of violating a state or local traffic law (other than parking), you must report it within 30 days to your employing motor carrier.  The notification must be in writing.

3.       CDL DOMICILE REQUIREMENT:  Section 383.23(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 the 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 that I possess:

MOTOR CARRIER INSTRUCTIONS:  For each Medical Examiner’s Certificate issued to a commercial motor vehicle driver, the motor carrier must verify that the medical examiner who signed the driver’s medical card is listed on the National Registry. This requirement is prescribed in 391.23 and 391.51.

391.23 INVESTIGATION AND INQUIRIES (m)(1):  The motor carrier must obtain an original or copy of the medical examiner’s certificate issued in accordance with 391.43, and any medical variance on which the certification is based, and, beginning on or after May 21, 2014, verify the driver was certified by a medical examiner listed on the National Registry of Certified Medical Examiners as of the date of issuance of the medical examiner’s certificate, and place the records in the driver qualification file, before allowing the driver to operate a CMV.

391.51 GENERAL REQUIREMENTS FOR DRIVER QUALIFICATIONS FILES (b)(9)(i): For drivers not required to have a CDL, a note relating to verification of medical examiner listing on the National Registry of Certified Medical Examiners required by 391.23(m)(1).   (b)(9)(ii) Until June 22, 2018, for drivers required to have a CDL, a note relating to verification of medical examiner listing on the National Registry of Certified Medical Examiners required by 391.23(m)(2).

RETENTION: This form is to be kept in the driver’s qualification file for 3 years.

A background investigation will be requested from consumer reporting agencies in connection with your employment application for employment purposes.   This information may be obtained in the form of consumer reports and/or investigative consumer reports. These reports may be obtained at any time after receipt of your authorization, and if you are hired by the Company, throughout your employment.

FAIR CREDIT REPORT ACT DISCLOSURE STATEMENT - In accordance with the provisions of Section 604(b)(2)(A) 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, criminal background and driving records may be obtained on you for employment purposes. These reports are required by Sections 382.413; 391.23 and 391.25 of the Federal Motor Carrier Safety Regulations. 

I have carefully read and understand this Disclosure and Authorization form.  By my signature below, I consent to the release of consumer reports and investigative consumer reports prepared by a consumer reporting agency, such as to the Company and its designated representatives and agents.  I understand that if the Company hires me, my consent will apply, and the Company may obtain reports, throughout my employment.

I also understand that information contained in my job application or otherwise disclosed by me before or during my employment, if any, may be used for the purpose of obtaining consumer reports and/or investigative consumer reports.

By my signature below, I authorize law enforcement agencies, learning institutions (including public and private schools and universities), information service bureaus, credit bureaus, record/data repositories, courts (federal, state and local), motor vehicle records agencies, my past or present employers, the military, and other individuals and sources to furnish any and all information on me that is requested by the consumer reporting agency.

By my signature below, I certify the information I provided on this form is true and correct.  I agree that this Disclosure and Authorization form in original, faxed, photocopied or electronic (including electronically signed) form, will be valid for any reports that may be requested by or on behalf of the Company.

AMERICAN VAN LINES INC

HOURS OF SERVICE DISCIPLINE POLICY

All drivers of this company will comply with the company policy as follows:

1.       A commercial motor vehicle driver will comply with the FMCSA Hours of Service Rules & Regulations per 49 CFR 395. 

2.       A commercial motor vehicle driver shall not falsify records of duty status.

3.       A commercial motor vehicle driver shall keep his/her records of duty status current to the time shown for the last change of duty status.

Repeated violations could result in progressive disciplinary action up to and including termination of employment:

•                     1st Offense - Verbal/Written Warning

•                     2nd Offense - remedial training

•                     3rd Offense - 3 Days Suspension Without Pay

•                     4th Offense - Immediate Termination

I acknowledge receiving a copy of this policy.    

The Department of Transportation prohibits the use of hand-held cell phones and imposes significant penalties on driver and employers.   Drivers who violate the restriction will face federal civil penalties up to $2,750 for each offense and disqualification from operating a commercial motor vehicle for multiple offenses.

Commercial truck and bus companies that allow their drivers to use hand-held cell phones while driving will face a maximum penalty of $11,000.   Additionally, states will suspend a driver’s commercial driver’s license (CDL) after two or more serious traffic violations.

Employees are not permitted to read or respond to e-mails or text messages while operating a motor vehicle on company business and/or on company time unless the device can be used hands-free.  This policy also applies to the use of PDA’s.

While driving, calls cannot be answers and must be directed to voice mail if your handheld device isn’t enabled for hands free use.  If an employee must make an emergency call (911), the vehicle should first be parked in a safe location.

Employees are responsible for the payment of civil penalties in the event a citation is issued.   If an employee is cited by any enforcement agency for cell phone use violations or if an employee is observed using a hand held device and the use is confirmed by one or more supervisory or management employees, the employee will be subject to discipline up to and including termination.  Correspondingly, any supervisor or management personnel found to allow, encourage, pressure or threaten adverse action against an employee for complying with this policy shall be subject to discipline up to and including termination.

I acknowledge receiving a copy of this policy.    

In connection with your application for employment with AMERICAN VAN LINES 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 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.

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 AMERICAN VAN LINES 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. 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.

Driver’s Name: _________________________________________________________________________________

The road test shall be given by the motor carrier or a person designated by it.  However, a driver who is a motor carrier must be given the test by another person.  The test shall be given by a person who is competent to evaluate and determine whether the person who takes the test has demonstrated that he or she is capable of operating the vehicle and associated equipment that the motor carrier intends to assign.

Rating of Performance (Satisfactory/Unsatisfactory)

_________         The pre-trip inspection as required by Sec. 392.7

_________             As applicable, Coupling and uncoupling of combination units, if the equipment he or she may drive includes combination units.

_________         Placing the vehicle in operation.

_________         Use of vehicle’s controls and emergency equipment.

_________         Operating the vehicle in traffic and while passing other vehicles.

_________         Turning the vehicle.

_________         Braking, and slowing the vehicle by means other than braking.

_________         Backing, and parking the vehicle.

_________         Other, Explain:

CERTIFICATION OF ROAD TEST

Instructions to Carrier:  If the road test is successfully completed, the person who gave it must complete the following certification in duplicate.  The original of the signed road test form and the original of the Certification of Road Test shall be retained in the driver qualification file of the person who was examined, and duplicate copies provided to the person examined.   Section 391.31 (e)(f)(g)(1)(2) of the Federal Motor Carrier Safety Regulations.

Drivers Name: ___________________________________________________________________________________

Type of Power Unit: ______________________________________________________________________________

This is to certify that the above-named driver was given a road test under my supervision on:

______________________________20________ consisting of approximately _________ miles of driving.  It is my considered opinion that this driver possesses sufficient driving skill to operate safely the type of commercial motor vehicle listed above.