DRIVER EMPLOYMENT APPLICATION

Declaration of Employment: This referes to any Gap in employment History

 

I understand that i must provide my complete employment history for the past three years and all CDL required employment fot he seven years proceding that.  Any Gap in Employmant longet then one month are explained as follows: 

To Be Read and Signed by applicant:

I authorize you to make such investigations and inquires of my personal, employment, financial or medical history and other related matters as may be necessary in arriving at an employment decision. (Generally inquires reguarding medical history will be only made if and after a conditional offer of employment has been extended).  I hereby release employers, schools, health care providors and other persons from all liability in responding to inwuires and releasing information on connection woth my application.

In the event of employment, I understand that false or misleading information given in my application or interviews may result in discharge.  i understand alsom that I am required to avide by all rules and regulations of the company.  

I understand information I provide reguarding current and/or previous employers may be used, and those employers will be contacted, for the purpose of investigating my safety and performance history as required by 49 CFR 391.23 (d) and (e).  i understand that I have the rights to:

- Review information provided by employers

-Have errors in the information corrected by previous employers and for those previous employers to re-send the corrected information to the prospective employer, and

-Have a rebuttal statement attached to the alledgd erroneous information, if the previous employer(s) and I cannot agree on the accuracy of the information.

This certifies this application was completed by me, and all entries on it and information in it are true and complete to the best of my knowledge.  

 

FAIR CREDIT REPORTING ACT DISCLOSURE STATEMENT

 In accordance eith the provisions of section 604 (b) (2) (A) of the fair credit reporting Act, Publuc Law 91-508, as amended by the Consumer Credit Reporting Act of 1966 (Title II, Subtitle D, chapter 1, of Puublic Law 104-208), you are being informed that reports verifying your previous employment, previous drig and alcohol test results, and your driving Record may be obtained on you for employment puropses.  

Your employer may obtain this infomation from Accufax, Equifax, Transunion, Experion or other vendors of information services. 

I understand that, as required by the Federal Motor Carrier Safety Regulations and company policy, all drivers must submit to alcohol and controlled substance testingas a condition of employment.  I also understand that any offer of employment will be contingent upon the results of an alcohol and contrilled substance test.

Therefore, I agree to submit to the following alcohol and controlled substance tests in accordance and as defined by the Federal Motor Carrier Safety Regulation and this companies policies:

- Pre-Employment, to determine employment eligibility

- Random

- Reasonable Suspicion

- Post Accident

CERTIFICATION OF COMPLIANCE WITH DRIVER LICENSE REQUIREMENTS

 Motor Carrier Instructions: The reqirements in Part 383 apply to every driver who operates in intrastate, interstatem or foreign commerce and operates a vehicle weighing 26,001 pounds or more can transport more then 15 people, or trnsports hazarsous materials that require placarding.

The requirements in Part 391 apply to every driver who operates in interstate commerce and operates a vehicle weighing 10,001 pounds or more, can transport more then 15 people, or transports hazardous materials that require placarding.

Driver Requirements: Part 383 and 391 of the Federal Motor Carrier Safety Regulations contain some requirements that you as a driver must comply with.  These requirements are in effect as of July 1, 1987.  They are as follows:

1.  You, as a commercial vehicle driver, may not possess more then one license.

2.  If you currently have more than one license, you should keep the license from your state of residence, and return the additional licenses to the states that issue them.  Destroying a license does not close the record in the state that issued it; you must notify the state.  If multiple license has been lost, stolen, or destroyed, you should close your record by notifying the state of issualbe that you no longer want to be licensed by that state.

3. Sections 392.42 and 383.33 of the Federal Motor Carrier Safety Regulations require that you notify your employer the NEXT BUSINESS DAY of any revocation or suspension of your drivers license.  In addition, Section 383.31 requires that any time you violate a state or federal local traffic law (other than parking), you must report it to your employing motor carrier and the state that issued your license with in 30 days.

DRIVER CERTIFICATION: I certify that I have read and understand the above requirements.

 

SAFETY PERFORMANCE HISTORY RECORDS REQUEST

Please sign below so that we may request your records from previous employers

CERTIFICATION OF VIOLATIONS

 MOTOR CARRIER INSTRUCTIONS: The company is required by the DOT to perform an annual records check, to ensure the company is aware of any and all violations committed by its drivers, including those in a private auto as well as any in a Commercial Motor Vehicle.

Please list in the below section all violations of motor vehicle traffic laws and ordinances (other than violations for parking) of which you have been convicted, or on account of which you have forfited bond of collateral during the last 12 months. (Per FMSCR 391.27)

I certify the following is a true and complete list of traffic vioplations require to be listed for which I have been convicted or forfited bond or collateral during the past 12 months

If no violations are listed above, I certify that I have not been convicted or forfetied bond or collateral on account of any violation (other than thise I provided under Part 383) required to be listed during the past 12 months.

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

 

IMPORTANT DISCLOSURE

 

REGUARDING BACKGROUND REPORTS FROM THE PSP Online Service

 

In connection with your application for employment with LEE TRANSPORT SYSTEMS, LLC . ("'Projective 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 .

 Wl1en 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 Reportil1g Act before Making any final adverse action. Jf 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 F ICSA; the name, address and the toll free telepl1one 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, d1en, wid1in 3 business days of receiving your request, together with proper identification, tl1e Prospective Employer must send or provide to you a copy of.our report and a summary of your rights under the fair Credit Reporting Act.

 Neither the Prospective Employer nor the Fl CSA contractor supplying the crash and safety information has the capability to correct any safety data that appears tn be incorrect. You may challenge the accuracy of the data by submitting a request ro

https://dataqs.fmcsa.dot.gov. If you challenge crash or inspection information reported by a. state, FMCSA cannot change or correct t 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 rt does not report, or assign or imply fault, it will include all Commercial Motor Vehicle (CMV) crashes where you were a dri er or co-driver and, here those crashes were reported to FMC-SA, regardless of fault. Similarly, all inspections. with or without violations, appear on the PSP repo1i. 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 LEE TRANSPORT SYSTEMS, LLC. ("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 of1he data by submitting a request to https://dataqs.fmcsa.dot.gov . If  I challenge crash or inspection in formation reported by a State, FMC SA 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 disp.la 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 FMCSA 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 provide d 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.

                                            

NOTICE: This form is made available to monthly account holders by NlC 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 Applicants written or electronic consent prior to accessing the Applicant's PSP report. Further. account holders are required by FMCSA to use tbe language contained in this Disclosure and Authorization form to obtain an Applicant's consent. The lru1guage must be used in whole, exactly as provided. Further, the language on  this form must exist 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 2111/2016

DRUG & ALCOHOL CLEARING HOUSE  

CONSENT FOR FULL QUERIES FOR PRE-EMPLOYMENT

  

I, understand that as required by the Federal Motor Carrier Safety Regulations [Drug & Alcohol Clearing House] and company policy, all driver MUST give consent to Atlantic Investigations LLC_ to access the FM SA Drug & Alcohol Clearing House data base to be sure that I have complied with the FM SA Drug and Alcohol regulations. I al o understand that any offer of employment wiJI be contingent upon the results of the report of the Drug & Alcohol Clearing Database.

 

I certify that I have read, understand, and agree to the condition of this consent and release form

DRUG & ALCOHOL CLEARINGHOUSE CONSENT FOR LIMITED QUERIES

 

NOTICE TO DRIVER: The Commercial Driver's License (COL) Drug & Alcohol Clearinghouse is a federal database containing information about COL drivers who have violated the Federal Motor Carrier Safety Administration's (FMCSA's) drug or alcohol regulations in 49 CFR Pari 382.Whether you have committed such a violation or not, each motor carrier for whom you drive is required to check whether the Clearinghouse has any information about you, both at the time of hire and annually. When conducting an annual Inquiry, the motor carrier has the option to request a "limited" report that only indicates whether the Clearinghouse has any information about you. Before a motor carrier may request a limited report, they must have your written authorization, per §382.701(b). This authorization may be valid for more than one year. If a limited query ever reveals that the Clearinghouse has information about you, you will be required to log in to the Clearinghouse website within 24 hours to grant electronic consent for the motor carrier to obtain your full Clearinghouse record.

 NOTICE TO MOTOR CARRIER: This consent form authorizes you to run a "limited query" to check whether the Clearinghouse has informati-on about the driver identified below. If it does, then you must obtain a full Clearinghouse record within 24 hours, per §382.701(b). This consent form must be retained until 3 years after the date of the last limited query you perform for this driver, based on the authorization below.

AUTHORIZATION

 

I hereby authorize LEE TRANSPORT SYSTEMS LLC. to conduct limited annual queries of the FMCSA's Drug & Alcohol Clearinghouse, to determine if a Clearinghouse record exists for me. This consent is valid from the date shown below until my employment with the above-named motor carrier ceases or until I am no longer subject to the drug and alcohol testing rules in 49 CFR Part 382 for the above-named motor carrier. I understand that if any limited query reveals that the Clearinghouse contains information about me, I must grant electronic consent within 24 hours, via the Clearinghouse website, for the motor carrier to obtain my full Clearinghouse record. Refusal to provide such consent will result in my removal from safety -sensitive duties.