Employment Application

Employment Application

In accordance with Federal and State equal employment opportunity laws, qualified applicants are considered for all positions without regard to race, color, region, sex, national origin, age, marital status, veteran status, non-job related disability, or any other protected group status.
TO BE READ AND SIGNED BY APPLICANT

I authorize you to make such investigations and inquiries of 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 also understand that I am required to abide by all rules and regulations of the Company.

I understand that information I provide regarding current and/or previous employer 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 understand I have the right to:
• Review information provided by previous employer(s)
• Have errors in the information corrected by previous employer(s) and for those previous employer(s) to re-send the corrected information to the prospective employer
• Have a rebuttal statement attached to the alleged erroneous information that I, and the previous employer(s) cannot agree on the accuracy of the information.
Name

First NameLast Name
Last 4 Of Social #
Signature
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 Anchors Oil Field Services, LLC (“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 Anchors Oil Field Services, 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 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.
Date

MonthDayYear
Date
Name

First NameLast Name
Signature
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.

NOTICE: The prospective employment concept referenced in this form contemplates the definition of “employee” contained at 49 C.F.R. 383.5.

LAST UPDATED 2/11/2016

EMPLOYMENT HISTORY

The Federal Motor Carrier Safety Regulations (49 CFR 391.21) require that all applicants wishing to drive a commercial vehicle list all employment for the last three (3) years. In addition, if you have driven a commercial vehicle previously, you must provide employment history for an additional seven (7) years (for a total of ten (10) years). Any gaps in employment in excess of one (1) month must be explained. Start with the last or current position, including any military experience, and work backwards (attach separate sheets if necessary). You are required to list the complete mailing address, including street number, city, state, zip; and complete all other information.

PLEASE INCLUDE 10 YEARS OF EMPLOYMENT HISTORY OR APPLICATION WILL NOT BE CONSIDERED, IF APPLICABLE.
CURRENT OR MOST RECENT EMPLOYMENT
Phone # of Contact/Supervisor
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Position Held
Dates Employed:
Reason For Leaving
Salary
Explain Any Gaps In Employment
Where you Subject to the FMCSR while employed:
Was your job designated as a safety sensitive function in any DOT regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40?
If Currently Employed do you give permission to call for reference (A 'no' answer does not disqualify you from the application process)

NEXT EMPLOYER
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Position Held
Dates Employed:
Reason For Leaving
Salary
Explain Any Gaps In Employment
Where you Subject to the FMCSR while employed:
Was your job designated as a safety sensitive function in any DOT regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40?
NEXT EMPLOYER
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Position Held
Dates Employed:
Reason For Leaving
Salary
Explain Any Gaps In Employment
Where you Subject to the FMCSR while employed:
Was your job designated as a safety sensitive function in any DOT regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40?

NEXT EMPLOYER
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Position Held
Dates Employed:
Reason For Leaving
Salary
Explain Any Gaps In Employment
Where you Subject to the FMCSR while employed:
Was your job designated as a safety sensitive function in any DOT regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40?
NEXT EMPLOYER
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Position Held
Dates Employed:
Reason For Leaving
Salary
Explain Any Gaps In Employment
Where you Subject to the FMCSR while employed:
Was your job designated as a safety sensitive function in any DOT regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40?
If needed please upload more employment history for the 10 year requirement.

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ACCIDENT RECORD FOR THE PAST 3 YEARS-list most recent first

Rows	Date:	Nature of Accident	Number of Fatalities	Number of Injuries	Chemical Spills (Y/N)
-
-
-
-

Check this box if none

TRAFFIC CONVICTIONS AND FORFEITURES FOR THE PAST 3 YEARS

Rows	Date	Violation	State of Violation	Penalty
-
-
-

Check this box if none
Have you ever been denied a license, permit, or privilege to operate a motor vehicle? If yes please explain:
Has any license, permit or privilege ever been suspended or revoked? If yes please explain:

DRIVERS LICENSE OR PERMITS HELD IN THE PAST 3 YEARS

Rows	STATE	LICENSE NUMBER	CLASS	ENDORSEMENT(S)	EXPIRATION DATE
-
-
-

How many years of CDL experience do you have?
How many years of Truck/Trailer combo experience do you have?

DRIVING EXPERIENCE- please list driving experience, if it doesn't apply put N/A

Rows	YES	NO	TYPE OF EQUIPMENT (VAN/TANK/FLAT/DUMP/REEFER)	TOTAL MILES
STRAIGHT TRUCK
TRACTOR AND SEMI-TRAILER
TRACTOR-TWO TRAILERS
TRACTOR-THREE TRAILER
MOTOR-COACH-SCHOOL BUS MORE THAN 8 PASSENGERS
MOTOR-COACH-SCHOOL BUS MORE THAN 15 PASSENGERS

List States Operated In The Last 5 Years
Which safe driving awards do you hold and from whom?
Please list any other qualifications that you have and which you believe should be considered.

EDUCATION

Rows	NAME AND LOCATION	COURS OF STUDY	YEARS COMPLETED	GRADUATED (YES/NO)	ANY ADDITIONAL DETAILS
HIGH SCHOOL
COLLEGE
OTHER

PROFESSIONAL REFERENCES-please list at least 3

Rows	FULL NAME	VALID PHONE NUMBER	YEARS KNOWN
-
-
-

PERSONAL REFERENCES-please list at least 3

Rows	FULL NAME	VALID PHONE NUMBER	YEARS KNOWN
-
-
-

For Faster processing, please upload a copy of your drivers license

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To be read and Signed by applicant

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.
Should be Empty:

Employment Application

APPLICANT INFORMATION