By my signature below, I certify under penalty of perjury that all of the foregoing information is true and complete, and I understand that
any falsification or omission of information may result in denial of employment; or, if I am employed by the Company, may result in termination regardless of the time lapse before discovery.
ARIZONA APPLICANTS ONLY: THE SMOKE-FREE ARIZONA ACT, A.R.S. § 36-601.01, PROHIBITS SMOKING IN PLACES OF EMPLOYMENT AND WITHIN 20 FEET OF ALL ENTRANCES, OPEN WINDOWS, OR VENTILATION SYSTEMS.
CALIFORNIA APPLICANTS ONLY: I understand the Company may obtain, without using the services of a third party investigative consumer reporting agency, public records pertaining to my character, general reputation, personal characteristics, etc. during its evaluation of my application for employment and, if employed, during my employment. By checking the following box, I waive my right to receive copies of public records obtained by the Company.
MARYLAND APPLICANTS ONLY: UNDER MARYLAND LAW, AN EMPLOYER MAY NOT REQUIRE OR DEMAND, AS A CONDITION OF EMPLOYMENT, PROSPECTIVE EMPLOYMENT OR CONTINUED EMPLOYMENT, THAT AN INDIVIDUAL SUBMIT TO OR TAKE A LIE DETECTOR OR SIMILAR TEST. EMPLOYER WHO VIOLATES THIS LAW IS GUILTY OF A MISDEMEANOR AND SUBJECT TO A FINE NOT EXCEEDING $100.
MASSACHUSETTS APPLICANTS ONLY: IT IS UNLAWFUL IN MASSACHUSETTS TO REQUIRE OR ADMINISTER A LIE DETECTOR TEST AS A CONDITION OF EMPLOYMENT OR CONTINUED EMPLOYMENT. AN EMPLOYER WHO VIOLATES THIS LAW SHALL BE SUBJECT TO CRIMINAL PENALTIES AND CIVIL LIABILITY.
MONTANA APPLICANTS ONLY: THE EMPLOYMENT RELATIONSHIP IS GOVERNED BY THE WRONGFUL DISCHARGE FROM EMPLOYMENT ACT. MONT. CODE ANN. § 39-2-901.
RHODE ISLAND APPLICANTS ONLY: IF YOU PROVIDE FALSE INFORMATION ABOUT YOUR ABILITY TO PERFORM THE ESSENTIAL FUNCTIONS OF THE JOB, WITH OR WITHOUT ACCOMMODATIONS, YOU MAY BE BARRED FROM FILING A CLAIM UNDER THE PROVISIONS OF THE WORKERS’ COMPENSATION ACT OF THE STATE OF RHODE ISLAND.
I understand that the information I provide regarding my current and/or prior 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. I understand that I have the right to:
- Review information provided by current/previous employers;
- Have errors in the information corrected by previous employers, and for those previous employers to resend the corrected information to the prospective employer; 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 information.
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. Note: A motor carrier may require an applicant to provide more information than that required by the Federal Motor Carrier
Safety Regulations