Applicant Instructions: If the answer to a question is no, none, or N/A, please fill in the blank accordingly. Do not leave any questions blank.

Transcription

1 855 Progress Industrial Blvd. Lawrenceville, Georgia Driver Application Referred by: Please completed forms back to: or fax to Applicant Instructions: If the answer to a question is no, none, or N/A, please fill in the blank accordingly. Do not leave any questions blank. Company Driver Contract Driver Date: Name First Middle Last Home Phone Date of Birth Cellular Phone Social Security Number Current Address and 3 years Previous Addresses: From To From To From To From To Education and Employment History: Circle the highest grade completed: Grade School: College: Post Graduate: Give a complete record of all employment including any unemployment or self-employment for the past 3 years, and all commercial driving experience for the past 10 years. Present or Last Employer: Name Address From To Position Held Supervisor Phone Reason for Leaving Were you subject to the FMCSR s while employed with this company? Yes No (check one) Was your position considered a safety-sensitive function in any DOT-regulated mode subject to controlled substance and alcohol testing requirements? Yes No (check one)

2 Next Previous Employer: Name Address From To Position Held Supervisor Phone Reason for Leaving Were you subject to the FMCSR s while employed with this company? Yes No (check one) Was your position considered a safety-sensitive function in any DOT-regulated mode subject to controlled substance and alcohol testing requirements? Yes No (check one) Next Previous Employer: Name Address From To Position Held Supervisor Phone Reason for Leaving Were you subject to the FMCSR s while employed with this company? Yes No (check one) Was your position considered a safety-sensitive function in any DOT-regulated mode subject to controlled substance and alcohol testing requirements? Yes No (check one) Next Previous Employer: Name Address From To Position Held Supervisor Phone Reason for Leaving Were you subject to the FMCSR s while employed with this company? Yes No (check one) Was your position considered a safety-sensitive function in any DOT-regulated mode subject to controlled substance and alcohol testing requirements? Yes No (check one) Next Previous Employer: Name Address From To Position Held Supervisor Phone Reason for Leaving Were you subject to the FMCSR s while employed with this company? Yes No (check one) Was your position considered a safety-sensitive function in any DOT-regulated mode subject to controlled substance and alcohol testing requirements? Yes No (check one)

3 Driving Experience Dates Approximate Total Equipment Class From To Number of Miles Straight Truck Tractor and Semi-Trailer Tractor Doubles/Triples Other Tanker, Flatbed, Specialized, etc. List states operated in for the past 5 years: List special courses and/or training completed (HazMat, PTD/DDC, etc.): List any Safe Driving Awards you earned and from whom: Accident Record for the past 3 years Date of Nature of Accidents (rear-end, Location of # of # of People Accident lane change, upset, etc.) Accident Fatalities Injured Traffic Convictions and Forfeitures for the past 3 years (do not include parking violations) Date Location Charge Penalty Driver s License (list each driver s license held in the past 3 years) State License # Type Endorsements Expiration Date Have you ever been denied a license, permit, or privilege to operate a motor vehicle? Yes No Has any license, permit, or privilege ever been suspended or revoked? Yes No Have you ever tested positive or refused a DOT controlled substance (drug) or alcohol preemployment test within the past two years from an employer who did not hire you? Yes No Have you ever been convicted of a felony? Yes No If the answer to any of the above is Yes, give details:

4 To be Read, Understood and Signed by the Driver Applicant It is agreed and understood that any misrepresentation given on this application shall be considered an act of dishonesty. It is also a violation of 49 CFR Making fraudulent or intentionally false statements or records, which is subject to federal penalty by the Federal Motor Carrier Safety Administration. It is agreed and understood that the motor carrier or his agents may investigate the applicant s background to ascertain any and all information of concern to applicant s record, whether same is of record or not, and applicant releases employers and persons named herein from all liability for any damages on account of his furnishing such information. It is also agreed and understood that under the Fair Credit Reporting Act, Public Law , I have been told that this investigation may include an investigating 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 application file. It is agreed and understood that this driver application in no way obligates the motor carrier to employ or hire the applicant. It is agreed and understood that if qualified and hired, I may be on a probationary period during which time I may be disqualified without recourse. 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. Driver Applicant s Signature Date If there are any additional comments, remarks, explanations, etc. about your skills, abilities or qualifications, please enter here: or fax completed application to: sdavis@performancetrucking.com or Fax: (678)

5 DRIVER S RIGHTS PERTAINING TO RELEASE OF DRIVER INFORMATION UNDER REGULATION Motor carriers have the responsibility to make the following investigations and inquiries with respect to each driver employed, other than a person who has been a regularly employed driver of the motor carrier for a continuous period which began before January 1, (a)(1) An inquiry into the driver s driving record during the preceding three years to the appropriate agency of every State in which the driver held a motor vehicle operator s license or permit during those three years; and (a)(2) An investigation of the driver s employment record during the preceding three years. (b) A copy of the driver record(s) obtained in response to the inquiry or inquiries to each State driver record agency as required must be placed in the Driver Qualification File within 30 days of the date the driver s employment begins and be retained in compliance with (c) Replies to the investigations of the driver s safety performance history must be placed in the Driver Investigation History File within 30 days of the date the driver s employment begins. This goes into effect after October 29, (d) Prospective motor carrier must investigate the information from all previous employers of the applicant that employed the driver to operate a CMV within the previous three years. This information must cover general driver identification and employment verification information, data elements as specified in for accident involving the driver that occurred in the three-year period preceding the date of the employment application, and any accidents the previous employer may wish to provide. (e) Prospective motor carrier must investigate the information from all previous DOT regulated employers that employed the driver within the previous three years from the date of the employment application in a safety-sensitive function that required alcohol and controlled substance testing specified by 49 CFR Part 40. Drivers have the following rights: 1. The right to review information provided by previous employers. 2. The right to have errors in the information corrected by the previous employer and for that previous employer to re-send the corrected information to the prospective employer. 3. 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. Drivers who wish to review previous employer-provided investigative information must submit a written request to the prospective employer when applying or as late as 30 days after employed or being notified of denial of employment. The prospective employer must provide this information to the applicant within five business days of receiving the written request. If the driver has not arranged to pick up or receive the requested records within 30 days of the prospective employer making them available, the prospective motor carrier may consider the driver to have waived his/her request to review the records. Drivers wishing to request correction of erroneous information in records must send the request for the correction to the previous employer that provided the records. After October 29, 2004, the previous employer must either correct and forward the information to the prospective motor carrier employer or notify the driver within 15 days of receiving the driver s request to correct the data that it does not agree to correct the data. Drivers wishing to rebut information in records must send the rebuttal to the previous employer with instruction to include the rebuttal in the driver s Safety Performance History. I acknowledge that I have read and understand the contents of this document Driver s Signature: Date: Driver Name (Printed):

6 PERFORMANCE TRUCKING, INC. - SUWANEE, GEORGIA EMPLOYMENT / DRUG & ALCOHOL VERIFICATION 1 st / 2 nd / 3 rd Company: Attn: Phone: Fax: Date: The person listed below has applied for a commercial driver s position with Performance Trucking Inc., and listed your company as a previous employer. Please complete the requested information in compliance with FMCSR (Investigation and Inquires) and (Inquires for Alcohol and Controlled Substances Information from Previous Employers) in accordance with the requirements of of this title. Your reply will be held in strict confidence and will in no way involve you in any responsibility. Applicant: S.S.N. The applicant lists dates of employment with your company from to Is this correct? Yes No If NO please provide the correct dates: to Type of Driver: T/T S/T Company O/O Team Other Equipment: Flatbed Van Reefer Tanker Other Experience: Local OTR Mountain Other Commodities Transported: Number of verified miles: Accidents: Please indicate the total number of accidents and details: Date Type Preventable DOT Recordable Location Y or N Y or N Y or N Y or N Y or N Y or N Reason for leaving your employ: Discharged Laid Off Resigned Would you re-hire this person? Yes No Upon Review Comments: DRUG AND ALCHOL INFORMATION Does this company conform to part 382 of FMCSR? Yes No Has this person tested positive for a controlled substance in the last three years? Yes No Has this person had a breath alcohol concentration of 0.04 or greater in the last three yrs. Yes No Has this person refused a required drug or alcohol in the last three years? Yes No Has this person had other violations of DOT agency drug and alcohol regulations, including FMCSR Subpart B of 382, violations of and/or 392.5? Yes No Has a previous employer reported a positive drug or alcohol test? Yes No Note: If Yes to any of the above questions, please give the SAP s name, address, and phone number for further reference. SAP Name: SAP Phone: SAP Adress: City: St: Zip NAME OF PERSON RELEASING INFORMATION: Date: Signature of person releasing Information: Title: I hereby authorize you to release all information concerning my employment, including oral assessments of my job performance, ability, fitness, alcohol and controlled substance testing results to each and every company (or their authorized agents), which may request such information in connection with my application for employment with said company. I hereby release you any and all liability of any type as a result of providing the above mentioned information to the above mentioned person. Applicant s Signature Witness s Signature **PLEASE RETURN TO FAX # ** Date Signed

7 DISCLOSURE OF PROCUREMENT OF CONSUMER REPORT AND/OR INVESTIGATIVE CONSUMER REPORT PLEASE READ THE FOLLOWING STATEMENTS CAREFULLY: PLEASE BE ADVISED that Performance Trucking, Inc may obtain a Consumer Report about you in order to evaluate your eligibility for employment purposes. It may be an Investigative Consumer Report, which may include information about your character, general reputation, personal characteristics, and mode of living. You have the right to request disclosure of the nature and scope of the report, which may involve personal interviews with sources such as your neighbors, friends, associates, or others. These reports may include credit information, credit history, employment history and reference checks, criminal and civil history information, motor vehicle records and moving violation reports ( driving records ), sex offender status reports, education verification, professional licensure verification, and other items. THE UNDERSIGNED HEREBY ACKNOWLEDGES THAT HE/SHE HAS READ THE FOREGOING DISCLOSURE. APPLICANT S SIGNATURE DATE PRINT NAME Employment

8 Client Name: Performance Trucking, Inc. Requestor s Name: Sondra Davis Client Account No.: Client Phone No.: AUTHORIZATION I HEREBY AUTHORIZE Performance Trucking, Inc (the End User ) to obtain consumer reports and/or investigative consumer reports at any time after receipt of this Authorization and, if I am hired, throughout my employment. To this end, I hereby authorize, without reservation, any person or entity, law enforcement agency, administrator, state or federal agency, institution, school or university (public or private), information service bureau, employer, or insurance company to furnish any and all background information to ESS Inc., 2500 Southlake Park, Birmingham, AL 35244, toll free , or its subcontractor or another outside organization acting on behalf of ESS. The term background information includes, but is not limited to, employment history, reference checks, criminal and civil history information, motor vehicle records, moving violation reports, sex offender status information, credit reports, education verification, professional licensure verification, drug testing, information related to my Social Security number, and information concerning workers compensation claims. I agree that a facsimile ( fax ), electronic or photographic copy of this Authorization shall be as valid as the original. I acknowledge receipt of the Disclosure Of Procurement Of Consumer Report And/Or Investigative Consumer Report. I understand I can view ESS s Privacy Policy on its website, You have the right to request from the End User a written summary of the rights of a consumer prepared pursuant to the Fair Credit Reporting Act, 15 U.S.C. 1681g(c). Signature of Employee or Prospective Employee Date IF THE EMPLOYEE OR PROSPECTIVE EMPLOYEE IS A MINOR CHILD UNDER THE AGE OF EIGHTEEN YEARS: I am the parent or legal guardian of the minor child who signed hereinabove; having read the foregoing Authorization, and in my capacity the minor s parent or legal guardian, I hereby authorize and consent to the obtaining of consumer reports and investigative consumer reports at any time after receipt of this Authorization and, if the minor is hired, throughout the minor s employment. Signature of Parent or Legal Guardian Date APPLICANT INFORMATION: TO BE COMPLETED BY APPLICANT: PLEASE USE BLACK INK The following is for identification purposes only to perform the background check and will not be used for any other purpose. Print: Last Name First Name Middle Initial Date of Birth Social Security Number Driver s License Number State Current Address: City State Zip Code Previous Address (Past 7 Years): City State Zip Code Previous Address (Past 7 Years): City State Zip Code Alias Names (Other names I have been known by): Degree Obtained Year Graduated Name of School City and State of School Last Name Used at Time of Graduation Searches to be Ordered Employment

9 Para informacion en espanol, visite o escribe a la Consumer Financial Protection Bureau, 1700 G Street N.W., Washington, DC A Summary of Your Rights Under the Fair Credit Reporting Act The federal Fair Credit Reporting Act (FCRA) promotes accuracy, fairness, and privacy of information in the files of consumer reporting agencies. There are many types of consumer reporting agencies, including credit bureaus and specialty agencies (such as agencies that sell information about check writing histories, medical records, and rental history records). Here is a summary of your major rights under the FCRA. For more information, including information about additional rights, go to or write to: Consumer Financial Protection Bureau, 1700 G Street N.W., Washington, DC You must be told if information in your file has been used against you. Anyone who uses a credit report or another type of consumer report to deny your application for credit, insurance, or employment or to take another adverse action against you must tell you, and must give you the name, address, and phone number of the agency that provided the information. You have the right to know what is in your file. You may request and obtain all the information about you in the files of a consumer reporting agency (your file disclosure ). You will be required to provide proper identification, which may include your Social Security number. In many cases, the disclosure will be free. You are entitled to a free file disclosure if: o A person has taken adverse action against you because of information in your credit report; o You are the victim of identity theft and place a fraud alert in your file; o Your file contains inaccurate information as a result of a fraud; o You are on public assistance; o You are unemployed but expect to apply for employment within 60 days. In addition, all consumers are entitled to one free disclosure every 12 months upon request from each nationwide credit bureau and from nationwide specialty consumer reporting agencies. See for additional information. You have the right to ask for a credit score. Credit scores are numerical summaries of your creditworthiness based on information from credit bureaus. You may request a credit score from consumer reporting agencies that create scores or distribute scores used in residential real property loans, but you will have to pay for it. In some mortgage transactions, you will receive credit score information for free from the mortgage lender. You have the right to dispute incomplete or inaccurate information. If you identify information in your file that is incomplete or inaccurate, and report it to the consumer reporting agency, the agency must investigate unless your dispute is frivolous. See for an explanation of dispute procedures. Consumer reporting agencies must correct or delete inaccurate, incomplete, or unverifiable information. Inaccurate, incomplete or unverifiable information must be removed or corrected, usually within 30 days. However, a consumer reporting agency may continue to report information it has verified as accurate. Consumer reporting agencies may not report outdated negative information. In most cases, a consumer reporting agency may not report negative information that is more than seven years old, or bankruptcies that are more than 10 years old Employment

10 Access to your file is limited. A consumer reporting agency may provide information about you only to people with a valid need usually to consider an application with a creditor, insurer, employer, landlord, or other business. The FCRA specifies those with a valid need for access. You must give your consent for reports to be provided to employers. A consumer reporting agency may not give out information about you to your employer, or a potential employer, without your written consent given to the employer. Written consent generally is not required in the trucking industry. For more information, go to You may limit prescreened offers of credit and insurance you get based on information in your credit report. Unsolicited prescreened offers for credit and insurance must include a toll-free phone number you can call if you choose to remove your name and address from the lists these offers are based on. You may opt-out with the nationwide credit bureaus at OPTOUT ( ). You may seek damages from violators. If a consumer reporting agency, or, in some cases, a user of consumer reports or a furnisher of information to a consumer reporting agency violates the FCRA, you may be able to sue in state or federal court. Identity theft victims and active duty military personnel have additional rights. For more information, visit Employment

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