I understand that the 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 pervious employers to re-send the corrected information to the prospective employers; and
- Have a rebuttal statement attached to the erroneous information, if the previous employer(s) and I cannot agree on the accuracy of the information
* Any gaps in employment and/or unemployment must be explained.
**The Federal Motor Carrier Safety Regulations (FMCSRs) apply to anyone operating a motor vehicle on a highway in interstate commerce to transport passengers or property when a vehicles: (1) weights or has a GVWR of 10,001 pounds or more, (2) is designed or used to transport 9 or more passengers, OR (3) is of any size and is used to transport hazardous materials in a quantity requiring placarding.
By submitting this document I hereby provide consent to A&G Commercial Trucking, GKD Management LP and/or it’s subsidiaries 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 A&G Commercial Trucking, GKD Management LP and/or it’s subsidiaries indicates that drug or alcohol violation information about me exists in the clearinghouse, FMCSA will not disclose that information to A&G, GKD or its subsidiaries without first obtaining additional specific consent from me.
I further understand that if I refuse to provide consent for A&G, GKD or its subsidiaries to conduct a limited query of the Clearinghouse, A&G, GKD or its subsidiaries must prohibit me from performing safety-sensitive functions, including driving a commercial motor vehicle, as required by FMCSA’s drug and alcohol program regulations.
I acknowledge receipt of the separate document entitled DISCLOSURE REGARDING BACKGROUND INVESTIGATION , DISCLOSURE REGARDING INVESTIGATIVE BACKGROUND INVESTIGATION and A SUMMARY OF YOUR RIGHTS UNDER THE FAIR CREDIT REPORTING ACT and additional state/city-specific notices and Summary of Rights and certify that I have read and understand those documents. I hereby authorize the evaluation of my driver file by A&G Commercial Trucking for compliance with state and federal laws and the acquisition of “consumer reports” (i.e. driving records, criminal history, social security verification, and/or education history) and/or “investigative consumer reports” (i.e. employment and/or education verification) by the Employer (as listed below) at any time after receipt of this authorization and throughout my employment, if applicable. In addition, I hereby authorize any law enforcement agency, administrator, state or federal agency, institution, school or university (public or private), information service bureau current and past employer, or insurance company to furnish any and all background information requested by A&G Commercial Trucking, 46054 Highway 645, Crump,TN 38327 and/or Employer itself. I agree that a facsimile (“fax”), electronic or photographic copy of this authorization shall be as valid as the original.
New York City Applicants only: By signing this form, you further authorize the Company to provide you with a copy of your consumer report, the New York City Fair Chance Act Notice Form, and any other documents, to the extent required by law, at the mailing address and/or email address you provide to the Company.
Washing State applicant only: You also have the right to request from the consumer reporting agency a written summary of your rights and remedies under the Washington Fair Credit Reporting Act.
Note to Residents of New Hampshire, Pennsylvania, Washington, Puerto Rico, and Canadian Provinces – British Columbia, Manitoba, New Brunswick, Newfoundland & Labrador, Northwest Territories, Nunavut, Prince Edward Islands, Quebec, Saskatchewan, and Yukon: State specific or Canadian general motor vehicle release forms must be completed and signed prior to obtaining the reports.
This document should NOT be construed as legal advice, guidance or counsel. Employers should consult their own attorney about their compliance responsibilities under the FCRA and applicable state law. A&G Commercial Trucking expressly disclaims any warranties or responsibility or damages associated with or arising out of information provided. EMployers seeking credit reports must provide additional notices pursuant to state law.
In connection with your application for employment with A&G Commercial Trucking (“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
If you agree that the Prospective Employer may obtain such background reports, please read the following and sign below:
I authorize A&G Commercial Trucking. (“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.
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.