TO BE READ AND SIGNED BY APPLICANT
I authorize you to make such investigations and inquire of my personal, employment, financial or medical history and
other related matters as may be necessary in arriving at a contract 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 inquires 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 or contract termination. I understand, also that I am required to abide by all rules and regulations of the Company. If I
terminate my contract by my own choice within 90 days, I agree to be responsible for the cost of the Drug Test and
other associated fees involved in my background check.
I understand that information I provide regarding current and/or previous employers 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 that I have the right to:
Review information provided by previous employers; Have errors in the information corrected by previous employers and for those previous employers to re-send the corrected information to the prospective carrier; 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 informationI also understand that if I terminate my contract within the first 90 days I will be responsible for $100 in pre-placement testing and associated costs.