Silchuk Transport Application Logo

  • DOT Application

  •  - -
  • {MainCompanyName}
     
    888-461-2950

  • Personal Information

    Step 1 of 5
  •  - -
    • + Add Phone Number 
    • + Add Phone Number 
    •  
    • + Add Email Address 
    • + Add Email Address 

  • Qualification Information

    Step 2 of 5

  • Drug and alcohol positive tests or refusals
    Have you ever tested positive, or refused to test on a pre-employment drug or alcohol test by an employer to whom you applied, but did not obtain safety-sensitive transportation work covered by DOT agency drug and alcohol testing rules in past three years, or have you ever tested positive or refused totest on any DOT-mandated drug or alcohol test?

  • License information

    Step 3 of 5

  • Current License Information
    Enter your current unexpired license information

  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof
  •  - -

  • Motor Vehicle Record

    Step 4 of 5

  • Revoked licenses, permits or privileges

  • Driving convictions

  • Drug and alcohol convictions

  • Please list all motor vehicle accidents in which you were involved in the past 3 years

  • Employment History

    Step 5 of 5

  • Fill out your employment
    Please provide 3 years of work history. In addition, please identify any employers for whom you have operated a commercial motor vehicle over the past 10 years. Your work history should include any military service, driving schools, and periods of unemployment, as applicable.

  •  - -
  •  - -

  • Previous Employers

    • + Add Previous Employer 1 
    •  - -
    •  - -

    • Silchuk Transport LLC
      Sioux Falls, South Dakota,
      57101
      (315) 480-9286


    • Employment Verification Request

      Hi,
      {firstName} {lastName} applied for a position at our company and listed {Employer1CompanyName} as a previous employer.
      So that we may fully evaluate this applicant, please verify the employment of {firstName}

      Thank you in advance,
      {MainCompanyName}

      P.S. As a reminder, FMCSA regulations require the verification of employment. We greatly appreciate your assistance to help us meet this requirement by responding
      in a timely manner.


      Name: {firstName} {lastName}
      Social Security#: {socialSecurity}
      Date of Birth: {DateOfBirth}
      Employment dates: {startDate187} - {date216}
      CDL driver: {whileEmployed291}


      Signature

       


      I specifically authorize {Employer1CompanyName} to release to {MainCompanyName}, for the past three years, general identifying information, employment dates, work experience, and any and all accident information as required by 49 C.F.R. 391.23(d) and (e)  



    • 1. Employment verification for {Employer1CompanyName}
      The applicant named above was or is employed by {Employer1CompanyName}? ____ YES ____ NO
      From: ____________ To: ______________
      The applicant drove a motor vehicle for {Employer1CompanyName}? ____ YES ____ NO
      If YES, type of vehicles operated? ____ Straight Truck ____ Tractor/Semi-Trailer ____ Flatbed ____ Cargo
      Tank ____ Doubles/Triples ____ Bus Other (specify) __________________________________
      Reason for leaving__________________________________________________________________


      2. Accident History
      Preventable? Haz Spill? Tow-Away?
      _____________ _________________________________ _____________ _____________ ___________ ___________ ___________
      _____________ _________________________________ _____________ _____________ ___________ ___________ ___________
      _____________ _________________________________ _____________ _____________ ___________ ___________ ___________
      _____________ _________________________________ _____________ _____________ ___________ ___________ ___________
      Completed by (Print name) _______________________
      Signature: _____________________________________
      Title: ____________________________
      Date: ____________________________

    • + Add Previous Employer 2 
    •  - -
    •  - -

    • Silchuk Transport LLC
      Sioux Falls, South Dakota,
      57101
      (315) 480-9286


    • Employment Verification Request

      Hi,
      {firstName} {lastName} applied for a position at our company and listed {Employer2CompanyName} as a previous employer.
      So that we may fully evaluate this applicant, please verify the employment of {firstName}

      Thank you in advance,
      {MainCompanyName}

      P.S. As a reminder, FMCSA regulations require the verification of employment. We greatly appreciate your assistance to help us meet this requirement by responding
      in a timely manner.


      Name: {firstName} {lastName}
      Social Security#: {socialSecurity}
      Date of Birth: {DateOfBirth}
      Employment dates: {startDate300} - {endDate301}
      CDL driver: {whileEmployed}


      Signature

       


      I specifically authorize {Employer2CompanyName} to release to {MainCompanyName}, for the past three years, general identifying information, employment dates, work experience, and any and all accident information as required by 49 C.F.R. 391.23(d) and (e)  



    • 1. Employment verification for {Employer2CompanyName}
      The applicant named above was or is employed by {Employer2CompanyName}? ____ YES ____ NO
      From: ____________ To: ______________
      The applicant drove a motor vehicle for {Employer2CompanyName}? ____ YES ____ NO
      If YES, type of vehicles operated? ____ Straight Truck ____ Tractor/Semi-Trailer ____ Flatbed ____ Cargo
      Tank ____ Doubles/Triples ____ Bus Other (specify) __________________________________
      Reason for leaving__________________________________________________________________


      2. Accident History
      Preventable? Haz Spill? Tow-Away?
      _____________ _________________________________ _____________ _____________ ___________ ___________ ___________
      _____________ _________________________________ _____________ _____________ ___________ ___________ ___________
      _____________ _________________________________ _____________ _____________ ___________ ___________ ___________
      _____________ _________________________________ _____________ _____________ ___________ ___________ ___________
      Completed by (Print name) _______________________
      Signature: _____________________________________
      Title: ____________________________
      Date: ____________________________

    • + Add Previous Employer 3 
    •  - -
    •  - -

    • Silchuk Transport LLC
      Sioux Falls, South Dakota,
      57101
      (315) 480-9286


    • Employment Verification Request

      Hi,
      {firstName} {lastName} applied for a position at our company and listed {Employer3CompanyName} as a previous employer.
      So that we may fully evaluate this applicant, please verify the employment of {firstName}

      Thank you in advance,
      {MainCompanyName}

      P.S. As a reminder, FMCSA regulations require the verification of employment. We greatly appreciate your assistance to help us meet this requirement by responding
      in a timely manner.


      Name: {firstName} {lastName}
      Social Security#: {socialSecurity}
      Date of Birth: {DateOfBirth}
      Employment dates: {startDate320} - {endDate321}
      CDL driver: {whileEmployed325}


      Signature

       


      I specifically authorize {Employer3CompanyName} to release to {MainCompanyName}, for the past three years, general identifying information, employment dates, work experience, and any and all accident information as required by 49 C.F.R. 391.23(d) and (e)  



    • 1. Employment verification for {Employer3CompanyName}
      The applicant named above was or is employed by {Employer3CompanyName}? ____ YES ____ NO
      From: ____________ To: ______________
      The applicant drove a motor vehicle for {Employer3CompanyName}? ____ YES ____ NO
      If YES, type of vehicles operated? ____ Straight Truck ____ Tractor/Semi-Trailer ____ Flatbed ____ Cargo
      Tank ____ Doubles/Triples ____ Bus Other (specify) __________________________________
      Reason for leaving__________________________________________________________________


      2. Accident History
      Preventable? Haz Spill? Tow-Away?
      _____________ _________________________________ _____________ _____________ ___________ ___________ ___________
      _____________ _________________________________ _____________ _____________ ___________ ___________ ___________
      _____________ _________________________________ _____________ _____________ ___________ ___________ ___________
      _____________ _________________________________ _____________ _____________ ___________ ___________ ___________
      Completed by (Print name) _______________________
      Signature: _____________________________________
      Title: ____________________________
      Date: ____________________________

    •  
    • + Add Unemployment Period 1 
    • + Add Unemployment Period 2 
    • + Add Unemployment Period 3 
    •  
    • + Add Driving School 

  • Legal Disclosures, Notices & Authorizations

    Documents: 1 of 2

  • AUTHORIZATION FOR RELEASE OF INFORMATION FOR EMPLOYMENT SCREENING

    Driver Record Screening Disclosure

    I hereby authorize {MainCompanyName} and its designated agents and representatives to conduct a comprehensive review of my driver record background through a consumer report and/or an investigative consumer report to be generated for employment, promotion, reassignment or retention as an employee. I understand that the scope of the consumer report/investigative consumer report may include information about my character, general reputation, personal characteristics, and mode of living as well as information that is not limited to, the following areas: names

    and dates of previous/current employment, work experience, Bureau of Workers Compensation/Claims, criminal history records (from local, state, federal, international and other law enforcement agencies’ records), sexual offenders lists, wants and warrants records, motor vehicle records, military records, educational verification, license verification, credit history, civil cases, OIG/GSA, USA PATRIOT Act/OFAC, any sanction lists, FBI finger printing, internet searches, social media information, and drug testing. Upon Request, {MainCompanyName} will supply a copy of the completed consumer report along with a copy of an individual’s rights under the Fair Credit Reporting Act.

    Authorization and Release

    I {firstName} {lastName}, authorize the complete release of these records or data pertaining to me which an individual, company, firm, corporation, or public agency may have. I authorize the full release of the information described above, without any reservation, throughout any duration of my employment at {MainCompanyName}. I hereby release {MainCompanyName}, and its agents, officials, representatives, or assigned agencies, including officers, employees, or related personnel both individually and collectively, from any and all liability for damages of whatever kind, which may at any time, result to me, my heirs, family or associates because of compliance with this authorization for release form. I certify that all information provided below is correct to the best of my knowledge. This authorization and consent shall be valid in original, fax, or copy form. The following information is required by law enforcement agencies and other entities for identification purposes when checking records. It is confidential and will not be used for any other purpose.


    Applicant’s Name: {firstName} {lastName}

    Middle Name {middleName}

    Maiden/AKA/Previous Name(s): {additionalNames}      


    Driver License Number: {licenseNumber}

    State: {licenseState}


    Date of Birth (this will not affect hiring decision): {DateOfBirth}

  • Notice to California Applicants: Under section 1786.22 of California Civil Code, you have the right to request from {MainCompanyName}, upon proper identification, the nature and substance of all information in files pertaining to you, including the sources of information, and recipients of any reports on you, which {MainCompanyName} has previously furnished within the two-year period preceding your request. You may view the file maintained on you by {MainCompanyName} during normal business hours. You may also obtain a copy of this file upon submitting proper identification. Upon making a written request, you may receive a summary of your report.

    Notice to Maine Applicants: Under Chapter 210 Section 1314 of Maine revised Statutes, you have the right, upon request, to be informed within 5 business days of such a request to whether or not an investigative consumer report was requested. If such report was obtained, you may contact the Consumer Reporting Agency and request a copy.

    Notice to Massachusetts Applicants: Under Mass. Ann. Laws chapter. 93 §§ 50, a Consumer Reporting Agency may furnish a report if intended to be utilized for employment purposes.

    Notice to New York Applicants: Under Article 25 Section 380-c (b) (2) of the New York General business Law, you have the right, upon written request, to be informed of whether or not an investigate consumer report was requested. Under Article 25 Section 380-g of the New York General Business Law, should a consumer report received by an employer contain criminal conviction information, the employer must provide to the applicant or employee who is the subject of the report, a printed or electronic copy of Article 23-A of the New York Correction Law, which governs the employment of persons previously convicted of one or more criminal offenses.


    Please initial here to acknowledge receipt of Article 23-A of New York Correction Law   {initials}   

      

    *   Date: {todaysDate482}

    Signature

    (Electronic signatures are NOT acceptable - This document must be physically signed by applicant)

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  • 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 {MainCompanyName} (“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

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

    I authorize {MainCompanyName} (“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. 


    Date:  {todaysDate482}


    Signature:   *   


    Name (Please Print): {firstName} {lastName}


    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 

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  • AGREEMENT TO CONDUCT TRANSACTION ELECTRONICALLY


    Consumer Disclosure.
    This electronic transaction service is provided on behalf of {MainCompanyName} (the “Employer”). The Employer is requesting that we – JotForm – provide legal documents, notices, and disclosures electronically and that we obtain your signature to legal agreements, authorizations, and other documents electronically.

    Scope of Agreement.
    You are agreeing:

    • To receive notices electronically, including legal notices, disclosures, copies of consumer reports, summaries of rights, correspondence regarding your application for employment and your background check, correspondence relating to any disputes, pre-adverse action and adverse action letters, and any other documents pertaining to the employment application and background check processes;
    • To authorize inquiries into your application for employment and for the conducting of background checks;
    • To abide by Terms of Service required by JotForm for use of its Platform and Site (as those terms are defined in the Terms of Service);
    • To provide electronic signatures over the course of your interaction with and use of the JotForm Platform and electronic transaction services;
    • To conduct transactions with the Employer, its background screening vendors, and JotForm electronically;
    • By proceeding forward and signing this Agreement, you are agreeing that (i) you have reviewed the consumer disclosure information above and (ii) you consent to (a) transact business with the Employer, its background screening vendors, and JotForm using electronic communications, (b) receive notices and disclosures electronically, and (c) utilize electronic signatures in lieu of using paper documents.

    You are not required to receive notices and disclosures electronically or sign documents electronically. If you do not wish to transact business electronically, you must close this browser window and notify the Employer that you do not wish to use the JotForm electronic transaction service.

    Hardware and Software Requirements.
    To use JotForm’s electronic transaction service, you must have (i) access to a personal computer or mobile device with an operating system capable of receiving, accessing, displaying, and either printing or storing information, (ii) the device must have either a touchscreen or a mouse, (iii) an Internet connection, and (iv) an Internet browser, such as Microsoft Edge®, Google Chrome®, Safari®, or Firefox®. Your Internet browser must support 256-bit encryption and Secure Sockets Layer (SSL) protocol. If you are able to see this Agreement to Conduct Transaction Electronically, your hardware and software should allow you to view, interact with, sign, and print or download all notices, disclosures, authorizations, and other documents which are part of this electronic transaction. When you have completed a document that requires an electronic signature, you may use your browser to view, print, screen capture, or download the document after you sign it. Additionally, copies of signed documents will be made available to you at the conclusion of the process.

    The Electronic Signature Process.
    During this electronic transaction process, you will be asked to sign online documents with an electronic signature. Please read the following carefully regarding the electronic signature process.

    First, you will sign this Agreement manually either (i) by using your finger or a stylus on a touchscreen or (ii) by using a mouse or pointing device with a display-only screen to write your signature in a signature box.
    Second, you will click a button below the signature box that says, “Agree and Sign.” By clicking this button, you are indicating your intent to sign the Agreement electronically.
    To abide by Terms of Service required by JotForm for use of its Platform and Site (as those terms are defined in the Terms of Service);
    Third, as you continue through this electronic transaction process, you will be asked to affirm you have received and read certain disclosures and notices by clicking a button titled “Continue.” Upon clicking that button, your electronic signature will be applied to the document.
    Fourth, during this process, you will be asked to make certain affirmations and certifications. You will make them by clicking the button titled “Continue” at which time your electronic signature will be applied to the document.
    Fifth, during this process, you will be asked to authorize certain transactions, such as authorizing your background check. Upon clicking a button titled “Authorize,” your electronic signature will be applied to the authorization.
    Once the signature process has been completed, your electronic signature will be binding as if you had signed a paper document with a pen.

    Paper and/or PDF Copies.
    At the conclusion of this transaction, you will have the opportunity to download and print any documents viewed or signed during this electronic transaction. You may also request free copies of documents or disclosures, if you prefer to do so, by contacting JotForm at: https://www.jotform.com/contact/ Proper identification may be required before certain documents are provided.

    Withdrawal of Consent.
    You may withdraw your consent at any time to conduct transactions electronically or to receive electronic documents, notices or disclosures. In order to withdraw consent, you must notify the Employer that you wish to withdraw consent and receive all future documents, notices, and disclosures in paper format. You must also notify JotForm at https://www.jotform.com/contact/ that you are withdrawing consent, providing your name, email address, date, telephone number, and postal address. Any withdrawal of consent will be effective only after a reasonable period of time to enable JotForm to process your withdrawal. Requests to withdraw consent will typically take several business days to complete as various third parties may need to be notified of your action. Withdrawal of your consent will have no legal effect on the validity, effectiveness, or enforceability of (a) any agreement, authorization, consent, or electronic signature provided by you prior to the effective date of your withdrawal, (b) any notice, form, letter, or other document that was provided or made available to you in electronic format prior to the effective date of your withdrawal, or (c) any portion of a consumer report that was compiled, prepared and furnished prior to the effective date of your withdrawal. There are no fees associated with withdrawal.

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  • Legal Disclosures, Notices & Authorizations

    Documents: 2 of 14

  • Disclosure and authorization for background investigation

    In connection with your application for employment with {MainCompanyName} (the “Company”) you understand a consumer report and/or investigative consumer report may be requested by the Company about you for employment purposes. These reports (also known as “background check reports”) may contain information about your character, general reputation, personal characteristics, and mode of living, whichever are applicable, and may include information obtained through personal interviews with neighbors, friends, or associates of yours. They may include the following types of information: criminal history, credit history, driving and/or motor vehicle records, public records, education or employment history, DOT drug and alcohol testing results, and medical information about your physical or mental health for purposes relevant to an employment determination, to the extent permitted by applicable law. The reports may contain a certified abstract of your complete driver's record in any state where you hold or have applied for a driver's license. No employer, prospective employer, or their agent may use information contained in a driving record related to the sealed juvenile record of an employee or prospective employee for any purpose unless required by federal law. The employee or prospective employee must furnish a copy of the court order sealing the juvenile record to the employer, prospective employer, or their agent.

    You have a right, upon written request made within a reasonable period of time after receipt of this disclosure, to be provided a disclosure of the nature and scope of the investigation requested. Such request should be made in writing to the Company.

    The scope of this notice and your authorization below is not limited to the present and, if you are hired, will continue throughout the course of your employment with the Company and allow us to conduct future screenings for retention, promotion, or reassignment, as permitted by law and unless revoked by you in writing.

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  • Legal Disclosures, Notices & Authorizations

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  • Acknowledgement and authorization for background check

    I acknowledge receipt of the separate document entitled DISCLOSURE REGARDING BACKGROUND INVESTIGATION and A SUMMARY OF YOUR RIGHTS UNDER THE FAIR CREDIT REPORTING ACT (which can be found here) and certify that I have read and understand both of those documents. By my signature below, I consent to the release of consumer reports and investigative consumer reports prepared by a consumer reporting agency to the Prospective Employer and JotFrom Customer, (the “Company”) and its designated representatives and agents. I understand that if the Company hires me, my consent will apply, and the Company may obtain reports, throughout my employment.

    I also understand that information contained in my job application or otherwise disclosed by me before or during my employment, if any, may be used for the purpose of obtaining consumer reports and/or investigative consumer reports.

    By my signature below, I authorize law enforcement agencies, learning institutions (including public and private schools and universities), information service bureaus, credit bureaus, record/data repositories, courts (federal, state and local), motor vehicle records agencies, my past or present employers, the military, and other individuals and sources to furnish any and all information on me that is requested by the consumer reporting agency.

    By my signature below, I certify the information I provided on this form is true and correct. I agree that this Disclosure and Authorization form in original, faxed, photocopied or electronic (including electronically signed) form, will be valid for any reports that may be requested by or on behalf of the Company.

    ADDITIONAL STATE LAW NOTICES

    If you are a California, Florida, Georgia, Maine, Maryland, Montana, New Jersey, New York or Washington applicant, please also note:

    CALIFORNIA: Under section 1786.22 of the California Civil Code, you may view the file maintained on you by the CRA during normal business hours. You may also obtain a copy of this file, upon submitting proper identification and paying the costs of duplication services, by appearing at CRA’s offices in person, during normal business hours and on reasonable notice, or by mail. You may also receive a summary of the file by telephone, upon submitting proper identification. CRA has trained personnel available to explain your file to you, including any coded information. If you appear in person, you may be accompanied by one other person, provided that person furnishes proper identification. A summary of your rights under CA Civil Code 1786.22 is being provided to you here.

    FLORIDA: I hereby provide consent for Agency to provide emergency contact information contained in my motor vehicle records.

    GEORGIA: I hereby provide consent for Agency to include photographs, fingerprints, computer images, medical and disability information in my driving records.

    MAINE: You have the right, upon request, to be informed of whether an investigative consumer report was requested, and if one was requested, the name and address of the consumer reporting agency furnishing the report. You may request and receive from the Company, within five business days of our receipt of your request, the name, address and telephone number of the nearest unit designated to handle inquiries for the consumer reporting agency issuing an investigative consumer report concerning you. You also have the right, under Maine law, to request and promptly receive from all such agencies copies of any such reports.

    MARYLAND: I hereby provide consent for Agency to report driving record entries that are more than 3 years old, records of a first offense of driving with an alcohol concentration, records or notations of probation before judgment, and records of the medical advisory board.

    MONTANA: I hereby provide consent for Agency to report driving records of traffic accidents that did not result in a conviction.

    NEW JERSEY: You have the right, upon request, to be informed of whether or not a consumer report was requested. If a consumer report is requested, you will be provided with the name and address of the consumer reporting agency (CRA) furnishing the report. You can dispute inaccurate information with the CRA, and inaccurate information must be corrected or deleted upon resolution of the dispute. A summary of your rights under the New Jersey Fair Credit Reporting Act is being provided to you here.

    NEW YORK: You have the right, upon request, to be informed of whether or not a consumer report was requested. If a consumer report is requested, you will be provided with the name and address of the consumer reporting agency furnishing the report. You may inspect and receive a copy of the report by contacting that agency. A copy of New York Correction Law Article 23-A is being provided to you here.

    WASHINGTON STATE: If we request an investigative consumer report, you have the right, upon written request made within a reasonable period of time after your receipt of this disclosure, to receive from us a complete and accurate disclosure of the nature and scope of the investigation we requested. A summary of your rights under the Washington Fair Credit Reporting Act is being provided to you here.

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  • To be read and signed by applicant

    I certify that I have read and understand all of the employment application. I certify that I completed this application and that all of the information I supply in this application packet is a full and complete statement of facts and contains no material omissions. It is understood that if any falsification is discovered, it will constitute grounds for rejection of application for employment or, if hired, dismissal from employment upon discovery thereof. 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. If hired, I agree to abide by all the rules and policies of the employer.

    I authorize you to make such investigations and inquiries of my personal, employment, financial or medical history and other related matters as may be necessary in arriving at an employment decision. (Generally, inquiries regarding medical history will be made only if and after a conditional offer of employment has been extended.) I hereby release JotFrom, employers, schools, health care providers and other persons from all liability in responding to inquiries and releasing information in connection with my application.

    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 current/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 employer;
    • 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.

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  • Legal Disclosures, Notices & Authorizations

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  • General consent for limited queries of the federal motor carrier safety administration (FMCSA) drug and alcohol clearinghouse


    I, {firstName} {lastName}, hereby provide consent to {MainCompanyName} 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. This limited query may be conducted by {MainCompanyName} on a periodic basis throughout my employment and no less than at least once a year.


    I understand that if the limited query conducted by {MainCompanyName} indicates that drug or alcohol violation information exists in the Clearinghouse, FMCSA will not disclose that information to {MainCompanyName} without first obtaining additional specific consent from me.


    I further understand that if I refuse to provide consent for {MainCompanyName} to conduct a limited query of the Clearinghouse, {MainCompanyName} must prohibit me from performing safety-sensitive functions, including driving a commercial motor vehicle, as required by FMCSA’s drug and alcohol program regulations.

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  • Legal Disclosures, Notices & Authorizations

    Documents: 6 of 14

  • ZERO DRUG/ALCOHOL TOLERANCE POLICY

    POLICY STATEMENT

    This company maintains a strict Zero Tolerance Policy regarding drug and alcohol use. Zero tolerance means that the company will absolutely not tolerate any drug use or impairment, no matter how minimal, from its employees. Violations of this policy will result in immediate and severe disciplinary action, including termination.


    Initial: {initials}

    DRUG AND ALCOHOL TESTING POLICY UNDER FMCSA REGULATIONS

    In compliance with the Federal Motor Carrier Safety Administration (FMCSA) regulations, all drivers are subject to drug and alcohol testing under the following circumstances:


    • Pre-Employment Testing - Required before an individual is hired to perform safety-sensitive functions.
    • Post-Accident Testing - Conducted following certain accidents as defined by FMCSA regulations.
    • Random Testing - Drivers may be randomly selected for testing by Foley Services at any time.
    • Reasonable-Suspicion Testing - Administered when there is reasonable cause to believe a driver is under the influence of drugs or alcohol.
    • Follow-Up Testing - Required for drivers who previously tested positive and are undergoing a return-to-duty process.


    Initial: {initials}

    REFUSAL TO SUBMIT TO A DRUG/ALCOHOL TESTING

    Refusal to submit to a drug or alcohol test is treated as a positive result. If an employee refuses testing, they will be immediately removed from performing any safety-sensitive functions and subjected to the same consequences as testing positive.


    Initial: {initials}

    CONSEQUENCES OF A POSITIVE TEST RESULT

    In the event of a positive drug or alcohol test result, the employee will be terminated

    immediately.


    Initial: {initials}
          

    CONTROLLED SUBSTANCE

    The following substances are classified as controlled substances and will be tested for as part of a 5-panel drug test:


    • Marijuana (THC) - including smoking, gummies, edibles, and CBD products
    • Cocaine
    • Amphetamines
    • Opioids
    • Phencyclidine (PCP)


    ALCOHOL USE

    In compliance with federal regulations, drivers are forbidden from consuming or being under the influence of alcohol within four hours of going on duty or operating a commercial motor vehicle (CMV). It is prohibited for drivers to use alcohol, be under the influence of alcohol, or have any measured alcohol concentration while on duty, operating, or in physical control of a CMV.

    The FMCSA has established 0.04% as the blood alcohol concentration (BAC) level at or above which a CDL commercial motor vehicle operator who is required to have a CDL, and is operating a commercial motor vehicle, is deemed to be driving under the influence of alcohol and subject to the disqualification sanctions in the Federal regulations


    ***ADMINISTRATIVE ACTION MAY BE TAKEN IF AN ALCOHOL CONCENTRATION OF 0.02 OR GREATER BUT LESS THAN 0.04 IS DETECTED***


    Initial:   {initials}


    _________________________________________________________________________________________


    This policy is in place to ensure a safe, drug-free workplace, and failure to adhere to it will result in immediate disciplinary action, including termination.

    ACKNOWLEDGMENT OF ZERO DRUG/ALCOHOL TOLERANCE POLICY

    I, the undersigned, acknowledge that I have read, understand, and agree to comply with the company's Zero Drug/Alcohol Tolerance Policy. I understand that failure to adhere to this policy, including but not limited to testing positive for controlled substances or alcohol, refusal to submit to testing, or any form of impairment, will result in immediate disciplinary action, including termination of employment.


    By signing below, I confirm that I have been informed of the policy and its consequences, and I agree to abide by all terms outlined within.


    _________________________________________________________________________________________


    Employee Name (Printed):   {firstName} {lastName}


    Employee Signature:   *   


    Date:   {todaysDate482}


  • Legal Disclosures, Notices & Authorizations

    Documents: 7 of 14


  • General Consent for Limited Queries of the Federal Motor Carrier Safety Administration (FMCSA) Drug and Alcohol Clearinghouse  


    I, {firstName} {lastName}, hereby provide consent to {MainCompanyName} 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 consent to multiple limited queries to be conducted for the duration of my employment. 


    I understand that if the limited query conducted by {MainCompanyName} indicated that drug or alcohol violation information about me exists in the clearinghouse, FMCSA will not disclose the information to {MainCompanyName} without first obtaining additional specific consent from me. 


    I further understand that if I refuse to provide consent for {MainCompanyName} to conduct a limited query of the Clearinghouse, {MainCompanyName} must prohibit me from performing safety-sensitive functions, including driving commercial motor vehicle, as required by FMCSA’s drug and alcohol program regulations. 



    *   

    Driver's Signature



    {todaysDate482}

    Date



  • Legal Disclosures, Notices & Authorizations

    Documents: 9 of 14
  • Image-538

  • I acknowledge that my employer provided me with a company drug and alcohol testing policy and education materials. I have reviewed my employer's policy, which includes the following information on 49 CFR Part 40 and Part 382:

  • Driver's Full Name:   {firstName} {lastName}

    Signature:   *   Date:     {todaysDate482} 

    Designated Employer Representative (DER): ___________________________________________

    DER Signature: _________________________________________________________________________

    Employer Keeps Original, Provides Scan or Copy to Driver

  • Legal Disclosures, Notices & Authorizations

    Documents: 10 of 14

  • HOURS OF SERVICE RECORD FOR FIRSTTIME OR INTERMITTENT DRIVERS

     

     

    Instuructions: When using a driver for the first time or intermittently, a signed statement must be obtained, giving the total time on duty (driving and on duty) during the immediate preceding seven days and the time at which the driver was last relieved from duty prior to beginning work.

  • Name: {firstName} {lastName}

  • I hereby certify that the information contained herein is true to the best of my knowledge and belief, and that my last period of release from duty was:

  •  - -
  •  - -

  • Signature: *

    Date: {todaysDate482}

  • Legal Disclosures, Notices & Authorizations

    Documents: 13 of 14

  • AUTHORIZATION FOR RELEASE OF INFORMATION FOR EMPLOYMENT SCREENING 


    Driver Record Screening Disclosure

    I hereby authorize {companyName} and its designated agents and representatives to conduct a comprehensive review of my driver record background through a consumer report and/or an investigative consumer report to be generated for employment, promotion, reassignment or retention as an employee. I understand that the scope of the consumer report/investigative consumer report may include information about my character, general reputation, personal characteristics, and mode of living as well as information that is not limited to, the following areas: names and dates of previous/current employment, work experience, Bureau of Workers Compensation/Claims, criminal history records (from local, state, federal, international and other law enforcement agencies’ records), sexual offenders lists, wants and warrants records, motor vehicle records, military records, educational verification, license verification, credit history, civil cases, OIG/GSA, USA PATRIOT Act/OFAC, any sanction lists, FBI finger printing, internet searches, social media information, and drug testing. Upon Request, {MainCompanyName} will supply a copy of the completed consumer report along with a copy of an individual’s rights under the Fair Credit Reporting Act.  


  •  - -

  • Notice to California Applicants: Under section 1786.22 of California Civil Code, you have the right to request from {MainCompanyName}, upon proper identification, the nature and substance of all information in files pertaining to you, including the sources of information, and recipients of any reports on you, which {MainCompanyName} has previously furnished within the two-year period preceding your request. You may view the file maintained on you by {MainCompanyName} during normal business hours. You may also obtain a copy of this file upon submitting proper identification. Upon making a written request, you may receive a summary of your report.

    Notice to Maine Applicants: Under Chapter 210 Section 1314 of Maine revised Statutes, you have the right, upon request, to be informed within 5 business days of such a request to whether or not an investigative consumer report was requested. If such report was obtained, you may contact the Consumer Reporting Agency and request a copy.

    Notice to Massachusetts Applicants: Under Mass. Ann. Laws chapter. 93 §§ 50, a Consumer Reporting Agency may furnish a report if intended to be utilized for employment purposes.

    Notice to New York Applicants: Under Article 25 Section 380-c (b) (2) of the New York General business Law, you have the right, upon written request, to be informed of whether or not an investigate consumer report was requested. Under Article 25 Section 380-g of the New York General Business Law, should a consumer report received by an employer contain criminal conviction information, the employer must provide to the applicant or employee who is the subject of the report, a printed or electronic copy of Article 23-A of the New York Correction Law, which governs the employment of persons previously convicted of one or more criminal offenses. 

    Please initial here to acknowledge receipt of Article 23-A of New York Correction Law:     {initials}


       
    Signature

    {todaysDate482}
    Date

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