• CDL Driver Application

    This is a driver qualification form. Please fill out the information below on this page. 
  • Dynasty Construction Services LLC

    9027 Eastside Drive Ext

    Newton, MS 39345

    (601) 887-2533

    (601) 649-4527

    Company DER: Billy Cleveland

  • Today's Date
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  • Driver Information

  • Date of Birth
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  • License Expiration
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  • Dynasty Construction Services LLC

  • 9027 Eastside Drive Ext
    Newton, MS 39345

  • Driver Application for Employment

  • Applicant Information

  • Print all information in blue or black ink only. All information must be filled out. If information is not applicable to you, please write none. Only completed applications will be accepted.
  • Date of application
     - -
  • Format: (000) 000-0000.
  • Date of birth
     - -
  • (required for commercial drivers)
  • List your address(es) of residency for the past three years:

  • Street
  • Education

  • Please circle the highest grade completed:
  • Have you ever been convicted of a felony?
  • Have you ever had any previous criminal or license actions on your records?
  • Do you have any pending hearings?
  • Employment History

  • All driver applicants to drive in interstate commerce must provide the following information on all employers during the preceding three years. Applicants to drive a commercial motor vehicle* in interstate or intrastate commerce shall also provide an additional seven years information on those employers for whom the applicant operated such vehicle. Print all information and complete all sections. Complete mailing addresses, street number, city, state, zip code and phone number are required.
  • List employers in reverse order starting with the most recent, or current, employer. Add additional sheets if necessary.
  • Format: (000) 000-0000.
  • Were you subject to the Federal Motor Carrier Safety Regulations while with this employer?
  • Was your job designated as a safety sensitive function in any DOT regulated mode subject to the alcohol and controlled substance requirements of 49 CFR Part 40?
  • Format: (000) 000-0000.
  • Were you subject to the Federal Motor Carrier Safety Regulations while with this employer?
  • Was your job designated as a safety sensitive function in any DOT regulated mode subject to the alcohol and controlled substance requirements of 49 CFR Part 40?
  • Format: (000) 000-0000.
  • Were you subject to the Federal Motor Carrier Safety Regulations while with this employer?
  • Was your job designated as a safety sensitive function in any DOT regulated mode subject to the alcohol and controlled substance requirements of 49 CFR Part 40?
  • Format: (000) 000-0000.
  • Were you subject to the Federal Motor Carrier Safety Regulations while with this employer?
  • Was your job designated as a safety sensitive function in any DOT regulated mode subject to the alcohol and controlled substance requirements of 49 CFR Part 40?
  • *includes vehicles having a GVWR of 10,001 pounds or more, vehicles designed to transport nine (9) or more passengers, or any size vehicle used to transport hazardous materials in a quantity requiring placarding.
  • Employment History (continued)

  • Format: (000) 000-0000.
  • Were you subject to the Federal Motor Carrier Safety Regulations while with this employer?
  • Was your job designated as a safety sensitive function in any DOT regulated mode subject to the alcohol and controlled substance requirements of 49 CFR Part 40?
  • Format: (000) 000-0000.
  • Were you subject to the Federal Motor Carrier Safety Regulations while with this employer?
  • Was your job designated as a safety sensitive function in any DOT regulated mode subject to the alcohol and controlled substance requirements of 49 CFR Part 40?
  • Format: (000) 000-0000.
  • Were you subject to the Federal Motor Carrier Safety Regulations while with this employer?
  • Was your job designated as a safety sensitive function in any DOT regulated mode subject to the alcohol and controlled substance requirements of 49 CFR Part 40?
  • Format: (000) 000-0000.
  • Were you subject to the Federal Motor Carrier Safety Regulations while with this employer?
  • Was your job designated as a safety sensitive function in any DOT regulated mode subject to the alcohol and controlled substance requirements of 49 CFR Part 40?
  • Format: (000) 000-0000.
  • Were you subject to the Federal Motor Carrier Safety Regulations while with this employer?
  • Was your job designated as a safety sensitive function in any DOT regulated mode subject to the alcohol and controlled substance requirements of 49 CFR Part 40?
  • Qualifications

  • Driver's License(s) - list each license held in the previous three (3) years
  • Expiration date
     - -
  • Expiration date
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  • Have you ever been denied a license, permit, or privilege to operate a motor vehicle?
  • Has any license, permit, or privilege ever been suspended or revoked?
  • List any special courses, training or awards which may pertain to the job for which you are applying:
  • Date
     - -
  • Driver Experience

  • List information regarding your driving experience for the last five years. If no driving experience, write none.
  • Rows
  • Traffic Convictions and Forfeitures

  • List all traffic convictions and forfeitures for the past three (3) years. Do not include parking violations.
  • Rows
  • Accident History

  • Federal Motor Carrier Safety Regulations require that all potential employees applying for a position to drive a motor vehicle furnish a list of all motor vehicle accidents in which the applicant was involved during the three (3) years preceding the date the application is submitted, specifying the date and nature of each accident and any fatalities or personal injuries it caused. (FMCSR, April 1, 2007 391.21 (b) (7))
  • Rows
  • 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. I authorize you to inquire of personal, employment, financial, medical and other related matters as may be necessary at arriving at employment decisions. I hereby release employers, schools, health care providers and other personnel from all liability in response to and release of information regarding my application. In the event of employment, I understand that false and/or misleading information given in my application or interview may result in discharge. I understand that I am required to abide by all rules and regulations of the company for which I am applying. I understand that information I provide regarding current and/or previous employers may be used, and those employers will be contacted, for the purpose of investigating my safety performance history as required by 49CFR391.23(d) and (e). I also understand I have the following rights: (1) Review of information provided by previous employers (2) Have errors in such information corrected and resent by previous employers to the prospective employer (3) Have a rebuttal statement attached to the alleged erroneous information if previous employer and I cannot agree on the accuracy of the information.
  • Date
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  • In compliance with Federal and State employment opportunity laws, qualified applicants are considered for all positions without regard to race, color, religion, sex, national origin, age, marital status or non-job related disability.

  • Request for INformation from Previous Employer

    SECTION 1: TO BE COMPLETED BY APPLICANT
  • Date
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  • I hereby authorize you to release the following information to Transafe, LLC and the below listed company for the purposes of investigation as required by section 391.23 and allowed by Section 383.35 of the Federal Motor Carrier Safety Regulations. You are released from any and all liability which may result from furnishing such information.

  • Date
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  • Information Provided Concerning the Disclosure and Authorization Pertaining to Consumer Reports Pursuant to the Fair Credit Reporting Act (FCRA)

  • The attached Disclosure and Authorization Pertaining to Consumer Reports Pursuant to the Fair Credit Reporting Act must be signed so we can conduct an inquiry with a consumer reporting agency and complete your investigation.

    Failure to complete this form and comply with the investigative requirements for the position you currently occupy or have been selected for could result in disciplinary action, up to and including removal. If Dynasty Construction Services, LLC intends to take any adverse action based in whole or in part on your consumer report, you are entitled to certain protections set out in the Fair Credit Reporting Act. These protections are provided below.

    A Summary of Your Rights Under the Fair Credit Reporting Act The federal Fair Credit Reporting Act (FCRA) promotes the accuracy, fairness, and privacy of information in the files of consumer reporting agencies. There are many types of consumer reporting agencies, including credit bureaus and specialty agencies (such as agencies that sell information about check writing histories, medical records, motor vehicle reports, and rental history records). Here is a summary of your major rights under the FCRA. For more information, including information about additional rights, go to www.ftc.gov/credit or write to: Consumer Response Center, Room 130-A, Federal Trade Commission, 600 Pennsylvania Ave. N.W., Washington, D.C. 20580.

    • You must be told if information in your file has been used against you. Anyone who uses a credit report or another type of consumer report to deny your application for credit, insurance, or employment – or to take another adverse action against you – must tell you, and must give you the name, address, and phone number of the agency that provided the information.

    • You have the right to know what is in your file. You may request and obtain all the information about you in the files of a consumer reporting agency (your “file disclosure”). You will be required to provide proper identification, which may include your Social Security number. In many cases, the disclosure will be free. You are entitled to a free file disclosure if:

    o a person has taken adverse action against you because of information in your credit report;

    o you are the victim of identity theft and place a fraud alert in your file;

    o your file contains inaccurate information as a result of fraud;

    o you are on public assistance;

    o you are unemployed but expect to apply for employment within 60 days.

    In addition, by September 2005 all consumers will be entitled to one free disclosure every 12 months upon request from each nationwide credit bureau and from nationwide specialty consumer reporting agencies. See www.ftc.gov/credit for additional information.

    • You have the right to ask for a credit score. Credit scores are numerical summaries of your credit-worthiness based on information from credit bureaus. You may request a credit score from consumer reporting agencies that create scores or distribute scores used in residential real property loans, but you will have to pay for it. In some mortgage transactions, you will receive credit score information for free from the mortgage lender.

    • You have the right to dispute incomplete or inaccurate information. If you identify information in your file that is incomplete or inaccurate, and report it to the consumer reporting agency, the agency must investigate unless your dispute is frivolous. See www.ftc.gov/credit for an explanation of dispute procedures.

    • Consumer reporting agencies must correct or delete inaccurate, incomplete, or unverifiable information. Inaccurate, incomplete or unverifiable information must be removed or corrected, usually within 30 days. However, a consumer reporting agency may continue to report information it has verified as accurate.

    • Consumer reporting agencies may not report outdated negative information. In most cases, a consumer reporting agency may not report negative information that is more than seven years old, or bankruptcies that are more than 10 years old.

    • Access to your file is limited. A consumer reporting agency may provide information about you only to people with a valid need -- usually to consider an application with a creditor, insurer, employer, landlord, or other business. The FCRA specifies those with a valid need for access.

    • You must give your consent for reports to be provided to employers. A consumer reporting agency may not give out information about you to your employer, or a potential employer, without your written consent given to the employer. Written consent generally is not required in the trucking industry. For more information, go to www.ftc.gov/credit.

    • You may limit “prescreened” offers of credit and insurance you get based on information in your credit report. Unsolicited “prescreened” offers for credit and insurance must include a toll-free phone number you can call if you choose to remove your name and address from the lists these offers are based on. You may opt-out with the nationwide credit bureaus at 1-888-5-OPTOUT (1-888-567-8688).

    • You may seek damages from violators. If a consumer reporting agency, or, in some cases, a user of consumer reports or a furnisher of information to a consumer reporting agency violates the FCRA, you may be able to sue in state or federal court.

    • Identity theft victims and active duty military personnel have additional rights. For more information, visit www.ftc.gov/credit.

    States may enforce the FCRA, and many states have their own consumer reporting laws. In some cases, you may have more rights under state law. For more information, contact your state or local consumer protection agency or your state Attorney General.

  • Disclosure and Authorization Pertaining to Consumer Reports Pursuant to the Fair Credit Reporting Act

    To be completed by Applicant
  • Date
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  • Expiration Date
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  • I,, hereby authorize Dynasty Construction Services, LLC to obtain such report(s) from any consumer reporting agency for employment purposes. This authorization is valid for the duration of my employment with Dynasty Construction Services, LLC.

  • This information will be used for the purpose of investigation as required by Sections 391.23 and 391.25 of the Federal Motor Carrier Safety Regulations and/or special assignments during which my job position requires such reports to be acquired. You are hereby released from any and all liability which may result from furnishing such information.

  • Date
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  • Certificate of Compliance with Driver License Requirements

  • Motor Carrier Instructions: The requirements in Part 383 apply to every driver who operates in intrastate, interstate, or foreign commerce and operates a vehicle weighting 26,001 pounds or more, can transport more than 9 people, or transports hazardous materials that require placarding.

    The requirement in Part 391 apply to every driver who operates in intrastate commerce and operates a vehicle weighing 10,001 pounds or more, can transport more than 9 people, or transports hazardous materials that require placarding.

    Driver Requirements: Parts 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) Possess Only One License: You, as a commercial vehicle driver, may not possess more than one motor vehicle operator’s license.

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

    2) Notification of License Suspension, Revocation, or Cancellation:

    Section 391.15 (b) (2) 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 driver’s license. In addition, Section 383.31 requires that any time you violate a state or local traffic law (other than parking), you must report it within 30 days to: 1) your employing motor carrier, and 2) the state that issued your license (If the violation occurs in a state other than the one which issued you license). The notification to both the employer and state must be in writing.

    The following license is the only one I will possess:

  • Expiration Date:
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  • Driver Certification: I certify that I have read and understand the above requirements.

  • Date
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  • Receipt of Controlled Substance and Alcohol Policy

  • Dynasty Construction Services, LLC

    9027 Eastside Drive Ext

    Newton, MS 39345

    Phone (601) 887-2533     Fax (601) 649-1527

     

    The company above has provided me with a copy of their Controlled Substances and Alcohol Testing Policy. By my signature, I acknowledge that I have read and understand this policy. 

  • Date
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  • Previous Pre-employment Drug or Alcohol Test Disclosure

  • The following information is required by the Federal Motor Carrier Regulations, Section 40.25for employment with the following company:

    Dynasty Construction Services, LLC

    9027 Eastside Drive Ext

    Newton, MS 39345

    Phone: (601) 887-2533     Fax: (601) 649-4527

  • Have you tested positive, or refused to test, on any pre-employment drug or alcohol test administered by an employer to which you applied for, but did not obtain, safety sensitive transportation work covered by DOT agency drug and alcohol testing rules during the past two (2) years? (check one)
  • I hereby certify that the above is a true response to the question above and I have answered it to the best of my knowledge:

  • Date
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  • If you answered yes to the above question, complete the information below:

  • Driver's Statement of On-Duty Hours

    (For first time or intermittent drivers)
  • Motor Carrier Instructions:

    When using a driver for the first time or intermittently, a signed statement must be obtained, giving the total time on duty (driving and on duty) during the immediate preceding seven days and the time at which the driver was last relieved from duty prior to beginning work.

  • Date 1
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  • Date 2
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  • Date 3
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  • Date 4
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  • Date 5
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  • Date 6
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  • Date 7
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  • I hereby certify that the information provided above is true and correct to the best of my knowledge and belief, and that I was last relieved from work at:

  • Date
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  • Date
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  • MEDICAL EXAMINER'S NATIONAL REGISTRY VERIFICATION

  • MOTOR CARRIER INSTRUCTIONS: The requirement to include verification of the Medical Examiner’s National Registry listing in the driver qualification file was published in the Federal Register April 20, 2012. Beginning May 21, 2014, motor carriers 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 (m)(1) Investigation and inquiries. 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 (b)(9) General requirements for driver qualification files. A note relating to verification of medical examiner listing on the National Registry of Certified Medical Examiners required by §391.23(m).

  • Select one of the following options:
  • I hereby certify that the motor vehicle in which I take/took the driving skills test is representative of the type of motor vehicle that I operate or expect to operate. By my signature affixed below, I certify under penalty of law, that all statements on this form are true and correct.

  • Date
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  • Receipt of Cell Phone Policy

  • Dynasty Construction Services, LLC

    9027 Eastside Drive Ext

    Newton, MS 39345

    The company above has provided me with a copy of their Cell Phone Policy. By my signature, I acknowledge that I have read and understand this policy. 

  • Date
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  • General Consent for Limited Queries of theFederal Motor Carrier Safety Administration (FMCSA)Drug and Alcohol Clearinghouse

  • Dynasty Construction Services, LLC

    9027 Eastside Drive Ext

    Newton, MS 39345

  • I,         , hereby provide consent for Dynasty Construction Services, LLC to conduct a limited query of the FMCSA Commercial Driver's License Drug and Alcohol Clearinghouse (Clearinghouse) to determine whether drug or alcohol violation information about me exists in the Clearinghouse.
    I understand that if the limited query conducted by Dynasty Construction Services, LLC indicates that drug or alcohol violation information about me exists in the Clearinghouse, FMCSA will not disclose that information to Dynasty Construction Services, LLC without first obtaining additional specific consent from me.
    I further understand that if I refuse to prove consent for Dynasty Construction Services, LLC to conduct a limited query of the Clearinghouse, Dynasty Construction Services, LLC must prohibit me from performing safety-sensitive functions, including driving a commercial motor vehicle, as required by FMCSA's drug and alcohol program regulations.
    This consent to conduct a limited query shall be active for the duration of my employment with Dynasty Construction Services, LLC.

  • Date
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  • Date of Birth
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  • APPLICANT'S STATEMENT

  • I certify that answers given herein are true and complete to the best of my knowledge.

    I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision.

    I understand that I will be subject to a background check, including Motor Vehicle Report if I will be operating a company vehicle during my employment. I also understand that my employment is contingent upon a negative drug screening conducted by a third party.

    I acknowledge that Dynasty will e-Verify my status for employment, and I will be required to furnish identification for this purpose.

    I HEREBY UNDERSTAND AND ACKNOWLEDGE THAT, IF HIRED, MY EMPLOYMENT RELATIONSHIP WITH THIS ORGANIZATION WOULD BE OF AN “AT WILL” NATURE, WHICH MEANS THAT THE EMPLOYEE MAY RESIGN AT ANY TIME AND THE EMPLOYER MAY DISCHARGE THE EMPLOYEE AT ANY TIME AND FOR ANY REASON. IT IS FURTHER UNDERSTOOD THAT THIS “AT WILL” EMPLOYMENT RELATIONSHIP MAY NOT BE CHANGED BY ANY WRITTEN DOCUMENT OR CONDUCT UNLESS SUCH CHANGE IS SPECIFICALLY AKNOWLEDGED IN WRITING BY AN AUTHORIZED EXECUTIVE OF THIS ORGANIZATION.

    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 employer.

  • Date
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  • IMPORTANT DISCLOSURE

    REGARDING BACKGROUND REPORTS FROM THE PSP Online Service
  • In connection with your application for employment with Dynasty Construction 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 Dynasty Construction 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
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  • 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.

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