TO BE READ ANO SIGNED BY APPLICANT
I authorize you to make sure Investigations and Inquiries to 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, 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 understand, also; that I am required to abide by all rules and regulations of the Company. I understand that information I provide regarding anent and/or previous employers may be used, and
those employer(s) will be contacted, for the purpose of investigating my safety performance histOf)' as required by 49 CFR 391.23(d) and (e).

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.