DRIVING RELATED SCHOOLS:

All employers must be listed for the previous 3 years and all CDL related employers must be listed for the previous 10 years. 

TRAFFIC CONVICTIONS

I certify that I have read and understood all of this employment application. lt is agreed and understood that the employer or his agents may investigate my background to ascertain any and all information of concern to my employent history, whether same is of record or not, and I release employers and other
persons named herein from all liability of any damages on account of furnishing such information. I understand that, as an applicant for a position with this company, I may be asked to demonstrate that I am capable of performing tasks which are pertinent to the job. I also understand that if offered a job, it will be conditioned on the results of a physica! examination and a drug test. 

I further certify that I am a genuine applicant for employment and this application is being submitted solely for the purpose of seeking employment with the employer and for no other reason. 

It is also agreed and understood that under the Fair Credit Reporting Act, Public Law 91-508; I have been told that this may include an investigative Consumer Report, including information regarding my character, general reputation, personal characteristics and mode of living. 

I agree to furnish such additional information and complete such examinations as may be required to complete my employment file. 

I also understand that misrepresentation or omission of information of facts may result in my rejection or dismissal. 

lf hired, I agree to abide by all the rules and policies of the employer. 

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.

To:

Name of previous employer

The person identified below has sought employment with this company as a driver subject to the alcohol and controlled substances testing provisions ofthe Federal Motor Carrier Safety Regulations of 49 CFR Part 382. Pursuant to 49 CFR. 382.413, with a driver's written consent, we must request the results ofsuch testing ofthis individual while in your service. Federal regulations require that we receive your reply within I4 days of the date shown above.

Person for whom information is required:

Name:{name}

SSN:{socialSecurity}

CDL Information:{cdlLicense}{state}{class}{endorcements}

By signing this form, 

 

 

Based upon a review ofyour company's Drug and Alcoholtesting policies, has the above individual in the past 3 years ever had the following?

                                                                                           Circle One

A confirmed Breath Alcohol Concentration (BAC) level of 0.04 or greater?	Yes	No
A Verified Drug Test?	Yes	No
Refused a Drug and/or an Alcohol Test	Yes	No
Other violations of DOT Agency Drug & Alcohol testing regulations	Yes	No
Did a previous employer report a drug and/or alcohol rule violation to you?	Yes	No
lf this employee has violated DOT Drug or Alcohol Testing Regulations, is documentationof successful completion of DOT return to duty requirements available?	Yes	No

Comments

Name

Date

Signature:

 

To:

Name of Previous Employer:

The person identified below has sought employment with this company as a driver.The applicant has listed your company as a former employer and has signed the waiver stated at the bottom of the page, waiving any claim ofliability against your company or its agents for information submitted in response to this inquiry.

Applicant: {name}

SSN#{socialSecurity}

I hereby authorize you to release all information concerning my employment including oral assessments of my job performance, ability, and fitness to Wayne Smith Trucking (or its designated agent) in connection with my application for employment with this company. I hereby release you from any and all liability of any type as a result of providing the above mentioned information to the above mentioned company.

To be completed by previous employer:

Employed From

To

To

# accidents in which driver was at fault:

Date:	Comments:
Date:	Comments:
Date:	Comments:

Has Applicant's CDL been suspended while in your employ?

If yes Please Explain:

Did Applicant pose either repeated or severe disciplinary problems?

Why did applicant leave your company?

Resigned

Fired

Laid Off

Would you re-emply this person?

Comments:

Name

Date

Signature

Click to edit this text...

PLEASE FILL  OUT AND FAX TO: SAFETY DEPT. FAX # 501-977-0048
Wayne Smith Trucking lnc., P.O. BOX 356, Morrilton, AR 72110.

THE BELOW DISCLOSURE AND AUTHORIZATION LANGUAGE IS FOR MANDATORY
USE BY ALL ACCOUNT HOLDERS
IMPORTANT DISCLOSURE REGARDING BACKGROUND REPORTS FROM THE PSP ONLINE SERVICE

ln connection with your application for employment with Wayne Smith Trucking, lnc. ("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 emplyment decision regarding you, the Prospective Employer will provide you with a copy ofthe report upon which its decision was based and written summary of your rights under the Fair Credit Reporting Act before taking any 6nal adverse action. lf any final adverse action is taken against you based upon your driving history or safety report, the Prospective Employer will notify you that the a(tion 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 ofthe report and may dispute with the FMCSA the accuracy or completeness of any information or report. lf 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. lf 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, itwill include all Commercial MotorVehicle (CMV) crashes where you were a driver or co-driver and where those crashes were reported to FMCSA, regardless offault. 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.

lf you agree that the Prospective Employer may obtain such background reports, please read the following and sign below:

I authorize Wayne Smith Trucking, lnc. ("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 that I may challenge the accuracy of the data by submitting a request to https://dataqs.fmcsa.dot.gov. lf 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 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.

Applicant Full Name:  {name}

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 Applicantb 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.
LAST UPDATED 12/22/1 5

I, {name} Do hereby authorize the Office of Driver Services to release my record of alcohol and drug test to:

Wayne Smith Trucking

41 WST Circle

Morrilton, Arkansas 72110

 

Date of Birth: {dateOf}

Driver License Number: {cdlLicense}

HireRight Customer Wayne Smith Trucking   Fax: (501) 354-3807 HireRight Account Code: WAYNESM

PART 1 . DISCLOSURE AND AUTHORIZATION FOR RELEASE OF INFORMATION FOR EMPLOYMENT PURPOSES - 49 CFR PART 391.23, DOT DRUG AND ALCOHOL TESTING

 

ln accordance with DOT Regulation 49 CFR Part 391.23, I hereby authorize release of my DOT-regulated drug and alcohol testing records by the DoT-regulated employer(s) listed below to HireRight for the purpose of HireRight transmitting such records to the HireRight customer listed above. I understand that information/documents released pursuant to this Part 1 is limited to the following DoT-regulated testing items, including pre-employement testing results, occuring during the previous three (3) years: (i) alcohol tests with a result of 0.04 or higher; (ii) verified positive drug tests; (iii) refusals to be
tested (including adulterated and/or substituted tests); (iv) other violations of DOT drug and alcohol testing regulations (i.e., violations of 49 CFR 382 Subpart B); (v) information obtained from previous employers of a drug and alcohol rule violation; and (vi) any documentation of completion of the return-to-duty process following a rule violation. lf any company listed below furnished HireRight with information concerning items (i) through (vi) above, I also authorize such company to furnish the following information to HireRight, if applicable: (i) dates of my negative drug and/or alcohol tests and/or tests with results below 0.04 during the previous three (3) years; and (ii) the name and phone number of any substance abuse professional who evaluated me during the three (3) years.

List all DOT-regulated employers you have applied with and/or worked for in a safety-sensative function during the previous (3) years.  If necessary, attach additional pages, including date, your name, soccial security Number and signature. 

By signing below, I certify that: (i) all information provided herein is complete and accurate; (ii) I have read and fully understand this Part 1 disclosure and authorization for release as well as the attached FMCSA Notification of Driver Rights and any applicable state law notices; (iii) prior to signing I was given an opportunity to ask questions and to have those questions answered to my satisfaction; (iv) I execute the authorization voluntarily and with the knowledge that the information obtained pursuant to this authorization could affect my eligibility for employment, promotion, retention or other lawful
purpose; (v) I understand I may review this document with legal counsel prior to signing; and (vi) facsimile or photographic copies of this authorization are as valid as the original.

Name: {name}

SSN: {socialSecurity}

PART 2. FMCSA NOTIFICATION OF DRIVER RIGHTS

ln compliance with 49 CFR Part 40 5391.23 you have certain rights regarding the safety performace history information that will be provided to prospective employers. l) You have the right to review information provided by previous employers. ll)You have the right to have errors in information corrected by
the previous employer and for that previous employer to re-send the corrected information to prospective employers. lll) You have the right to have a rebuttal statement attached to the alleged erroneous information, if the previous employer and the driver cannot agree on the accuracy of the information. (2)
Drivers who have previous DOT regulated employment history in the preceding three years and wish to review previous employer-provided investigative information must submit a written request to prospective employers. This may be done at any time, including when applying, or as late as 30 days after being
employed or being notified of denial of employment. Prospective employers must provide this information within five business days of receiving the written request. lf prospective employers have not yet received the requested information from the previous employer, then the five day deadline will begin
when the requested safety performance history information is received. lf you have not arranged to pick up or receive the requested records within 30 days of prospective employers making them available, the prospective employers may consider you to have waived your request to review the record.

DISCLOSURE AND AUTHORIZATION REGARDING BACKGROUND INVESTIGATION FOR EMPLOYMENT PURPOSES

 

DISCLOSURE

 

WAYNE SMITH TRUCKING (the "Company") may request from a consumer reporting agency and for employment-related
purposes, a "consumer report(s)" (commonly known as "background reports") containing background information about you in
connection with your employment, or application for employment, or engagement for services (including independent
contractor or volunteer assignments, as applicable).
HireRight, LLC ("HireRight") will prepare or assemble the background reports for the Company. HireRight is located and can be
contacted at 100 Centerview Dr, Nashville, TN 37214, (800) 400-2761, www.hirerrqht.com.
The background report(s) may contain information concerning your character, general reputation. personal characteristics,
mode of living, or credit standing. The types of background informationthat may be obtained include, but are not limited to:
criminal history; litigation history; motor vehicle record and accident history; social security number verification; address and
alias history; credit history; verification of your education, employment and earnings history; professional licensing, credential
and certification checks; drug/alcohol testing results and history; military service; and other information

AUTHORIZATION

 

I hereby authorize Company to obtain the consumer reports described above about me.

By clicking submit, I understand the information in this application for employment to be true, and I have not falsified any part of this application and I understand that doing so is against the law.  I also undertstand that all signatures filled out on this application to be my real signature.