Dowell Express Driver Application Form

This application is obtained as a requirement of the Federal Motor Carrier Safety Regulations Part 391.21 and wil be used to check the background and character of the applicant. This application must be completed in full and no parts are to be left blank. Areas that do not pertain to you should be marked NONE or N/A. This application wil not be processed until it has been completed in ful, signed and dated.

TRAFFIC CONVICTIONS AND FORFEITURES FOR THE PAST 3 YEARS (OTHER THAN PARKING VIOLATIONS)

Application For Employment 

TO BE READ AND SIGNED BY APPLICANT Please read Carefully before signing

I certify that the information contained in this application is correct to the best of my knowledge and understand that falsification or misstatement of material facts in this application or any other personnel record is grounds for disqualification from further employment consideration or may be cause for discharge from employment in accordance with company policy

I understand that company policy requires that l undergo a medical evaluation which includes a drug/alcohol screen at company expense. Any offer of employment is contingent upon my successful completion of the medical evaluation and dri and alcohol screening results. Should I be hired, I also understand that my employment with the company will be at will and can therefore be terminated wi or without cause and with or without notice, at the option of either myself or the company. I further understand that no company representative, other than the companies President or Safety Supervisor has the authority to enter into any agreement for employment for any specified period of time.

In connection with my application for employment with the company. I understand that consumer reports which may contai public record information may be requested from various organizations. These reports may include the following types of information: Names and dates of previous employment, reason for termination, work experience, accidents, etc. I further understand that such reporis may be requested from various service organizations and I may be required to sign a separate release for their services. I also understand that such reports may contain public record information concerning my driving record. Additional information may be requested from various state agencies or companies conceming previous driving anc employment records, and these requests may be made to other agencies which may have such information on file. I also understand that my name, address and social security number or any other information required wil be supplied to the state agency maintaining such information as called for by the Federal New Hire Reporting Laws.

I AUTHORIZE, WITHOUT RESERVATION, ANY PARTY OR AGENCY CONTACTED BY THE COMPANY TO FURNIS THE ABOVE INFORMATION.

This information may be used in the hiring or promotion process and if I am denied employment or promotion, that I have th right to make a request to The Company, upon proper identification, of ali information in its files on me at the time of my request.

I hereby authorize the procurement of consumer reports) and if hired, this authorization shall remain on file and shall serve ongoing authorization for the procurement of information at any time during my employment period.

I authorize and agree to assist the Company in lis investigation of my past employers, schools and activities. I also release said companies, schools and organizations from all liability for supplying such investigative information.

In consideration of my employment, I agree to conform to al policies, procedures, work rules, regulations of the company are the Federal Motor Carrier Safety Regulations.

DISCLOSURE AND AUTHORIZATION FORM

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

IMPORTANT DISCLOSURE
REGARDING BACKGROUND REPORTS FROM THE PS.P Online Service

In connection with your application for employment with Dowell Express 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 Reportin 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 Employe 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 MCSA 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.fincsa.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 simply 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 ("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 (S) 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.fincsa.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 assigu, 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.

 

Notice: This form is made availble to monthly account holder by NIC on behalf of the U.S. Department of Transportation, Federal Motor Carrier Safety Administrtion (FMCSA). Account holders are required by federal law to obtain an Applicants written or electronic consent prior to accessing the Applicants PSP report. Further, account holders are required by FMCSA to use the language contained in this Disclosure and Authorization form to obtain an applicants consent. The language must be used in whole, excatly as provided. Further, the language on this form must exist as one stand-alone document. Th language may NOT be included with other consent forms or any other language. 

NOTICE: The propective employment concept referenced in this form contemplates the definition of "employeee" contained at 49 C.F.R. 383.5

Last Updated 2/11/2016

PRE-EMPLOYMENT DRUG TESTING CONSENT AND RELEASE FORM

I hereby consent to submit to urinalysis and/or other tests as shal! be determined by DOWELL EXPRESS INC in the selection process of applicants for employment, for the purpose of determining the drug content thereof. I agree that U.S. DRUG TEST CENTER may collect these specimens for these tests and may test them or forward them to a testing laboratory designated by the Company for analysis. I further agree to and hereby authorize the release of the results of said tests to the Company. I understand that it is the current use of illegal drugs that would prohibit me from being employed at this Company.

I further agree to hold harmless the Company and its agents (including the above named physician of clinic) from any liability arising in whole or part, out of the collection of specimen testing, and use of the information from said testing in connection with the Company's consideration of my application of employment.

I further agree that a reproduced copy of this pre-employment consent and release form shall have the same force and effect as the original.
I have carefully read the foregoing and fully understand its contents. I acknowledge that my signing of this consent and release form is a voluntary act on my part and that I have not been coerced into signing this document by anyone.