PDP QUICK Driver Application

(A) DRIVER GENERAL INFORMATION
Full Name*

First NameMiddle NameLast Name
SSN*
Must have 9 digits
Verify SSN*
Must have 9 digits
Date of Birth*

MonthDayYear
1) Current Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
1) Cell Phone #*
1) E-mail*
1) # of years lived at current address*

(B) DRIVER’S LICENSE
a) Current Driver's License #*
a) State*
a) Type*
a) Expiration Date*

MonthDayYear
UPLOAD FRONT OF CDL*

Browse Files
Picture must be clear and readable, Only jpg, jpeg and png Formats are acceptable Cancelof
UPLOAD BACK OF CDL*

Browse Files
Picture must be clear and readable, Only jpg, jpeg and png Formats are acceptable Cancelof
b) Did you carry any additional Driver's License in any other issuing states besides the current Driver's License?*

No, I did not have any additional Driver's Licenses in any other states besides the current Driver's License.Yes, I had additional Driver's Licenses in other states
b) Previous Driver's License
b) State
b) Type
b) Expiration Date

MonthDayYear
c) Did you carry any additional Driver's License in any other issuing states besides the current Driver's License?

No, I did not have any additional Driver's Licenses in any other states besides the current Driver's License.Yes, I had additional Driver's Licenses in other states
c) Previous Driver's License
c) State
c) Type
c) Expiration Date

MonthDayYear
(B) Section 383.21 FMCSR states “No person who operates a commercial motor vehicle shall at any time have more than one driver’s license”.*

I certify that I DO NOT HAVE MORE THEN ONE ACTIVE motor vehicle Driver's License, and NO MORE OTHER motor vehicle Driver's Licenses other then listed above.
(B) Applicant's Certification*

I understand and allow for my Motor Vehicle Record (MVR) be pulled from DMV by CARRIER.
(B) BTO Company Name
(B) Applicant's Full Name
(B) Applicant's Signature*
(B) Date Signed

MonthDayYearHourMinutesAM/PM Option

(C) ACCIDENT RECORD FOR THE PAST 3 YEARS

Each driver shall furnish a list to the motor carrier of all motor vehicle accidents and traffic violations in the past 36 months. If the New Hire Driver has not had a traffic accident or been convicted of, forfeited bond, or collateral on account of any traffic violation, which must be listed, he/she shall so certify (Section 391.23).
How many accidents did you have for the past 3 years?*
Check this box if you have had no motor vehicle accidents or traffic violations. If you have no motor vehicles accidents or traffic violations to report.

I certify that I have not been involved in any motor vehicle accidents, convicted of, or forfeited bond, or collateral on account of any traffic violation required to be listed during the past 36 months.
1) Accident Date

MonthDayYear
1) Accident Nature
1) # of Fatalities
1) # of Injuries
1) Chemical Spills

YesNo
2) Accident Date

MonthDayYear
2) Accident Nature
2) # of Fatalities
2) # of Injuries
2) Chemical Spills

YesNo
3) Accident Date

MonthDayYear
3) Accident Nature
3) # of Fatalities
3) # of Injuries
3) Chemical Spills

YesNo

(E) TRAFFIC FINES AND FORFEITURES

Other than parking violations
How many Traffic Convictions and Forfeitures for the past 3 years? (Other than parking violations)*
Driver's Certification

I certify that there are no Traffic Convictions or Forfeitures to report.
1) Date Convicted

MonthDayYear
1) Violation
1) State
1) Penalty
Forfeited bond, Collateral and/or points
2) Date Convicted

MonthDayYear
2) Violation
2) State
2) Penalty
Forfeited bond, Collateral and/or points
3) Date Convicted

MonthDayYear
3) Violation
3) State
3) Penalty
Forfeited bond, Collateral and/or points

(H) PRE-EMPLOYMENT SCREENING PROGRAM (PSP)

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 PDP TRUCKING INC OR THEIR BUSINESS TRUCK OPERATOR (BTO) (“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
(H) APPLICANT'S AUTHORIZATION: If you agree that the Prospective Employer may obtain such background reports, please read the following and sign below:*

I authorize PDP TRUCKING INC AND/OR THEIR BUSINESS TRUCK OPERATOR (BTO) (“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.
(H) Date Signed

MonthDayYearHourMinutesAM/PM Option
(H) Applicant's Signature*
(H) BTO Company Name
(H) Applicant's Full Name
(H) Applicant's Current Address
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

CARRIER COMPANY AUTHORIZED TO GET PSP: PDP TRUCKING INC OR THEIR BUSINESS TRUCK OPERATOR (BTO)

(K) APPLICANT'S SIGNATURE

TO BE READ BY APPLICANT AND SIGNED
FAIR CREDIT REPORTING ACT DISCLOSURE STATEMENT

In accordance with the provisions of Section 604(b)(2)(A) of the Fair Credit Reporting Act, Public Law 91-508, as amended by the Consumer Credit Reporting Act of 1996 (Title II, Subtitle D, Chapter 1 of Public Law 104-208), you are being informed that reports verifying your previous employment, previous drug and alcohol test results, and your driving record may be obtained for employment purposes. These reports are required by Sections 382.413(40.25), 391.23, and 391.25 of the Federal Motor Carrier Safety Regulations.
(K) APPLICANT"S CERTIFICATION:*

It is agreed and understood that any misrepresentations of information given above shall be considered an act of dishonesty. I release CARRIER and persons named herein from all liability for any damages occurred as a result of furnishing such information. I understand that the information in this application will be used and that prior employers will be contacted for purposes of investigation as required by 391.23 of the Motor Carrier Safety Regulations. Furthermore, I understand that I may be required to meet D.O.T. physical (and other) requirements, and that I must meet insurance requirements to be eligible for employment. I agree and understand that this application for employment in no way obligates the employer to employ me. I agree and understand that if hired I will be in a probationary status. I further understand that employment is “At Will” and may be terminated any time, with or without notice, and with or without reason given, regardless of length of employment or method of pay, and that pay will cease upon date of termination. This certifies that I completed this application, and that all entries on it and information in it are true and complete to the best of my knowledge. I have read the above-mentioned certification and physical/job requirements and feel that I can meet these requirements for the position I am applying for.
(K) APPLICANT'S STATEMENT:*

I certify and agree that any material misrepresentation (deliberate or otherwise) or omission of facts or information in my application or interview may be justification for refusal of employment. This application is a sincere effort to obtain employment and for no other purpose. If I am employed, falsification or omission of any information may result in termination. If offered employment, I understand that the offer may be conditional upon verification of information I provide, as well as other information obtained by the Company. In applying for employment I understand that the Company may make a thorough investigation of my entire work and personal history (including credit checks and criminal background), and may verify all data given in my application for employment, related papers, or oral interviews. I authorize such investigation and the giving and receiving of any information requested by the Company, and stand that falsification of data given or any derogatory information discovered as a result of this investigation may prevent my being hired, or if hired, may subject me to immediate dismissal if the company considers such information to be pertinent to employment. I agree that my employment may be terminated by the Company with or without cause at any time without liability whatsoever, except for wages or salary as may have been earned at the date of termination. If requested by management, I authorize any physician, hospital, clinic, or laboratory to release any information that may be necessary to determine my ability to satisfactorily perform the duties of a job I am being considered for, prior to employment, or in the future during my employment with Company. I understand that management may make efforts to accommodate individual preferences, but that business needs may make the following conditions mandatory: Overtime, Out-of-Town Travel, Shift Work, Rotating Work Schedule, or a work schedule other than Monday through Friday. I understand and accept these as conditions of my employment or continued employment. I understand that no employment contract is being offered or created at this time. No employee has a contract of employment with this Company unless it is IN WRITING and signed by an authorized officer of the Company. I also understand that if I am employed, my employment will be for an indefinite period of time, and that the Company can change wages, benefits, and conditions of employment at any time, with or without notice, and without prior approval of any employee or employee group, and that any legal action regarding my employment must be initiated and maintained in the court of jurisdiction nearest the home office of the Company.
(K) APPLICATION ACKNOWLEDGMENT:*

I hereby certify that all information submitted to CARRIER in connection with my online application is true and correct. I understand that I am under a continuing obligation to advise CARRIER of any changes which may occur after application submission. I understand and agree that the omission, misrepresentation, or concealment of any significant fact in any statement may be considered sufficient reason for the denial of my application or dismissal after employed. I understand that decisions of the CARRIER's Recruiting Department are final.
(K) Applicant's Signature*
(K) BTO Company Name
(K) Applicant's Full Name
(K) Date Signed

MonthDayYearHourMinutesAM/PM Option
Should be Empty:

PDP - BTO APPLICATION

(A) DRIVER GENERAL INFORMATION

(A) DRIVER GENERAL INFORMATION

(B) DRIVER’S LICENSE

(C) ACCIDENT RECORD FOR THE PAST 3 YEARS

(D) DRIVING EXPERIENCE

(E) TRAFFIC FINES AND FORFEITURES

(H) PRE-EMPLOYMENT SCREENING PROGRAM (PSP)

(I) DRIVER'S PHYSICAL REQUIREMENTS

(K) APPLICANT'S SIGNATURE

PDP - BTO APPLICATION

(A) DRIVER GENERAL INFORMATION

(A) DRIVER GENERAL INFORMATION

(B) DRIVER’S LICENSE

(C) ACCIDENT RECORD FOR THE PAST 3 YEARS

(D) DRIVING EXPERIENCE

(E) TRAFFIC FINES AND FORFEITURES

￼(H) PRE-EMPLOYMENT SCREENING PROGRAM (PSP)

(I) DRIVER'S PHYSICAL REQUIREMENTS

(K) APPLICANT'S SIGNATURE

(H) PRE-EMPLOYMENT SCREENING PROGRAM (PSP)