Are you legally authorized to work in the United States?

Transcription

1 DRIVER APPLICATION FOR EMPLOYMENT We are an equal opportunity employer, dedicated to non-discrimination employment on the basis of race, color, age, religion, sex, national origin, handicap, disability or marital status. Southeast Milk, Inc., is a drug free work place. Per Subpart B-Qualification and Disqualification of Drivers: (2) Can read and speak the English language sufficiently to converse with the general public, to understand highway traffic signs and signals in the English language, to respond to official inquiries, and to make entries on reports and records. of application Position Applied For Minimum Salary Requirement Who referred you Mail in Employment Agency State Agency Walk-in Other to our company? Advertisement College Recruiting Employee Referral Have you ever worked for this company? Yes No Have you ever applied for this company? Yes No On what date will you be available to start? Are you available to work all shifts? Yes No Where? Where? Would you accept employment in another city? Yes No Are you legally authorized to work in the United States? Yes No Preference When? When? General Information Last Name First Middle Initial Social Security Number - - Present Address City State Zip Code How Long? Previous Address City State Zip Code How Long? Telephone Home ( ) Cell ( ) Have you ever been fired or asked to resign by an employer? Yes No of Birth? If yes, please explain. Have you ever been convicted of, or pled guilty, no contest or nolo contendere to a crime, misdemeanor or felony, in the past ten (10) years? Or have you received any type of driving infraction within the past 5 years? Answering yes to any of these questions does not automatically remove an applicant from eligibility. Yes No If yes, please explain. Have you ever been a defendant in a civil action for intentional tort(s) (e.g. assault, battery, or intentional infliction of emotional distress), or formally accused of an unlawful employment practice (e.g. sexual or racial harassment)? Yes No If yes, please explain. If related to anyone who works for this Company, state name and location. Are you bound by any non-solicitation agreements which would restrict your ability to prospect for business? Yes No Are there any contractual or non compete restrictions on your ability to work at SMI or it s subsidiaries? Yes No Name of person to be notified in case of emergency Education Circle highest grade completed: High School: College: Name and location of the last school attended: Highest degree earned: Telephone number ( ) Revised 11/12/2013

2 Employment History All employment for the previous 10 years must be covered below, including jobs held while in school or in the military. Record your present or last position first and list back in chronological order. Be sure to complete all questions for each job. Ask for an additional form if necessary. CPlease explain all periods of unemployment. All information provided in this section may be used for the purpose of investigating safety performance history as required by of the FMCSRs. Applicants have the right to review the information provided by previous employers; the right to have errors corrected by previous employer's and the information resent; and the right to have a rebuttal statement attached to alleged erroneous information. Name Address Employer From Position Held: City State Zip Salary/Wage: To Contact Person Phone Number Subject to FMCSRs: Yes No Reason for Leaving: Drug & Alcohol Testing? Yes No Name Address Employer From Position Held: City State Zip Salary/Wage: To Contact Person Phone Number Subject to FMCSRs: Yes No Reason for Leaving: Drug & Alcohol Testing? Yes No Name Address Employer From Position Held: City State Zip Salary/Wage: To Contact Person Phone Number Subject to FMCSRs: Yes No Reason for Leaving: Drug & Alcohol Testing? Yes No Name Address Employer From Position Held: City State Zip Salary/Wage: To Contact Person Phone Number Subject to FMCSRs: Yes No Reason for Leaving: Drug & Alcohol Testing? Yes No Name Address Employer From Position Held: City State Zip Salary/Wage: To Contact Person Phone Number Subject to FMCSRs: Yes No Reason for Leaving: Drug & Alcohol Testing? Yes No Have you ever worked for any of these employers under a different name or had a driver license under a different name? Yes No If yes, under what name?

3 Driver Experience and Qualifications State License No. Type Exp. Driver Licenses A. Have you ever been denied a license, permit or privilege to operate a motor vehicle? Yes No B. Has any license, permit or privilege ever been suspended or revoked? Yes No C. Have you ever been disqualified subject to Section 391 of the Federal Motor Carrier Safety Regulations? Yes No If the Answer to either A, B or C is yes, attach statement giving details Class of Equipment Straight Truck Tractor & Semi-Trailer Tractor Two Trailers Tanker Auto Carrier Refrigerated Equipment Other List geographic areas operated in for last five years. Driver Experience s Have You Ever From To Driven in: Rain Fog Snow Ice Rain Fog Snow Ice Rain Fog Snow Ice Rain Fog Snow Ice Rain Fog Snow Ice Rain Snow Fog Ice How Long Approx. Miles Operated Last Accident Accident Review for the Past 3 Years (Attach sheet if more space is needed) Failure to disclose information may result in rejection of this application. Nature of Accident Fatalities (Head-on, Rear-end, Upset, Etc ) Injuries Next previous Next Previous Traffic Convictions and Forfeitures for the past 3 Years (Other than Parking Violations) Failure to disclose information may result in rejection of this application. If none write none. Location Charge Penalty (Attach sheet if more space is needed)

4 Other Experience and Qualifications Show any trucking, transportation or other experience that may help in your work for this company. List courses and training other than shown elsewhere in this application. List special equipment or technical materials you can work with (other than those already shown). References Give the names of three persons not related to you, whom you have known at least one year. Name Phone Number Business Years Acquainted Employment Application Certification I hereby authorize Southeast Milk, Inc., and its representatives to investigate all statements contained in this application, to interview the references and previous employers listed in this application. It is agreed and understood that Southeast Milk, Inc., and its agents may conduct background evaluations to ascertain any and all information of concern, whether some is of record or not. I authorize the references and previous employers listed to give Southeast Milk, Inc., all facts, opinions and evaluations concerning my previous employment and any other information they may have, personal or otherwise, and I release all employers and persons named herein from all liability for any damages on account of their furnishing such information. I also authorize Southeast Milk, Inc., to conduct and/or obtain a criminal record check and to obtain any available driving record. If I am offered employment, I understand that such an offer will be contingent upon satisfactory results of a background investigation, including a drug screen test, a road test and a new medical examiner s certificate. If then employed, I understand that I will be required to serve a ninety (90) day probationary period. I further understand that my employment and compensation can be terminated, with or without cause or notice, at any time, regardless of the successful completion of my probationary period, at the option of either the Company or myself. I further understand and voluntarily agree as a condition of employment or my continued employment that I may be required by Southeast Milk, Inc., to submit to a urinalysis or other drug screen test, and that my refusal to take such test(s) when notified to do so, or positive test results will disqualify me from consideration for employment, or if I am then employed, will result in my immediate dismissal. I hereby certify that this application was completed by me, and that all of the facts and information listed are true and complete to the best of my knowledge. I further certify that I have read, understand, and agree to the above. I understand that any false, incomplete or misleading information given by me on this application is sufficient cause for rejection of this application or dismissal if already employed. Applicant Signature: :

5 Addendum to Employment Application DOT regulations prohibit SMI to utilize a driver to perform a safety-sensitive function (driving a commercial motor vehicle) if there is an admission of a positive test, or a refusal to test, until and unless SMI is provided with documents showing successful completion of the return-to-duty process in accordance with DOT regulations. Yes, I have tested positive for drugs/alcohol, and or refused a DOT required test for drugs/alcohol while applying for or working in a DOT Safety Sensitive Position in the three years preceding the date of this application. No, I have not tested positive for drugs/alcohol, or refused a DOT required test for drugs/alcohol while applying for or working in a DOT Safety Sensitive Position in the three years preceding the date of this application. This certifies that I completed this addendum to the employment application, and that all information therein is true and complete to the best of my knowledge. I also understand that misrepresentation or omission of information or facts may result in my rejection or dismissal. Applicant Signature

6 Southeast Milk, Inc., Gustafson, LLC, Sunshine State Dairy Farms, LLC Authorization for Release of Consumer Reports In connection with my application for employment, and/or employment with this company, I understand and am hereby notified by this document that Southeast Milk, Inc., Gustafson, LLC, or Sunshine State Dairy Farms, LLC, is authorized to request a consumer report from a consumer reporting agency for evaluation of me for employment (i.e., employment, promotion, reassignment, or retention as an employee). I understand that these consumer reports may contain information from public records, including written, oral, or other communications bearing on my credit worthiness, credit standing, credit capacity, character, general reputation, personal characteristics, or mode of living, which may or may not be used as a factor for employment purposes. I further understand that inquiries may include, but are not limited to, criminal convictions, motor vehicle records, education and previous employment verification. In addition, I understand that you may request information from various federal, state, and other agencies which maintain records concerning my past activities and history. I authorize without reservation any party or agency contacted by this employer to furnish the abovementioned information. Prospective employees have the following rights regarding investigative information that will be provided: The right to review information provided by previous employers; The right to have errors in the information corrected by the previous employer for that previous employer to re-send the corrected information to the prospective employer; The right to have a rebuttal statement attached to the alleged erroneous information, if the previous employer and the applicant cannot agree on the accuracy of the information. I further authorize ongoing procurement of the above-mentioned reports at anytime, either during the time my application for employment is being considered or throughout the duration of my employment in the event I am hired. Print Your Name: : Enter Your Signature:

7 Southeast Milk, Inc. Gustafson, LLC Sunshine State Diary Farms, LLC Applicant Copy In the event you are hired and become an employee of Southeast Milk, Inc., Gustafson, LLC or Sunshine State Dairy Farms, LLC, the Fair Credit Reporting Act (FCRA) requires you receive a summary of FCRA consumer rights as issued by the Federal Trade Commission. A Summary Of Your Rights Under the Fair Credit Reporting Act (FCRA) Para información en español, visite o escribe a la Consumer Financial Protection Bureau, 1700 G Street N.W., Washington DC The federal Fair Credit Reporting Act (FCRA) promotes the 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: a person has taken adverse action against you because of information in your credit report; you are the victim of identity theft and place a fraud alert in your file; your file contains inaccurate information as a result of fraud; you are on public assistance; 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 credit-worthiness 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.

8 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. 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 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 States may enforce the FCRA, and many states have their own consumer reporting laws. In some cases, you may have more rights under state law. For more information, contact your state or local consumer protection agency or your state Attorney General. For Information about your Federal rights contact:

9 TYPE OF BUSINESS: CONTACT: 1. a. Banks, savings associations, and credit unions with a. Consumer Financial Protection Bureau total assets of over $10 billion and their affiliates G Street NW Washington, DC b. Such affiliates that are not banks, savings associations, or b. Federal Trade Commission: credit unions also should list, in addition to the CFPB: Consumer Response Center FCRA Washington, DC (877) To the extent not included in item 1 above: a. National banks, federal savings associations and federal a. Office of the Comptroller of the Currency branches and federal agencies of foreign banks Customer Assistance Group 1301 McKinney Street, Suite 3450 Houston, TX b. State member banks, branches and agencies of foreign b. Federal Reserve Consumer Help Center banks (other than federal branches, federal agencies and PO Box 1200 Insured State Branches of Foreign Banks), commercial Minneapolis, MN lending companies owned or controlled by foreign banks, and organizations operating under section 25 or 25A of the Federal Reserve Act c. Nonmember Insured Banks, Insured State Branches of c. FDIC Consumer Response Center Foreign Banks, and insured state savings associations 1100 Walnut St., Box #11 Kansas City, MO d. Federal Credit Unions d. National Credit Union Administration Office of Consumer Protection (OCP) Division of Consumer Compliance and Outreach (DCCO) 1775 Duke Street Alexandria, VA Air carriers Asst. General Counsel for Aviation Enforcement & Proceedings Aviation Consumer Protection Division Department of Transportation 1200 New Jersey Avenue, S.E. Washington, DC Creditors Subject to Surface Transportation Board Office of Proceedings, Surface Transportation Board Department of Transportation 395 E Street, S.W. Washington, DC Creditors Subject to Packers and Stockyards Act, 1921 Nearest Packers and Stockyards Administration area Supervisor 6. Small Business Investment Companies Associate Deputy Administrator for Capital Access United States Small Business Administration 409 Third Street, SW, 8 th Floor Washington, DC Brokers and Dealers Securities and Exchange Commission 100 F Street, N.E. Washington, DC Federal Land Banks, Federal Land Bank Associations, Farm Credit Administration Federal Intermediate Credit Banks and Production Credit 1501 Farm Credit Drive Associations McLean, VA Retailers, Finance Companies, and All Other Creditors Not FTC Regional Office for region in which the creditor Listed Above operates or Federal Trade Commission: Consumer Response Center - FCRA Washington, DC (877)

10 HireRight Customer: Company Name: Southeast Milk, Inc. Company Contact Name: Dawn Sculley TRUCKING INDUSTRY: Fax #: (352) DOT D/A Disclosure and Authorization HireRight Account Code: KUWDJ Send to Fax# (800) PART I DISCLOSURE AND AUTHORIZATION FOR RELEASE OF INFORMATION FOR EMPLOYMENT PURPOSES 49 CFR PART , DOT DRUG AND ALCOHOL TESTING In accordance with DOT Regulation49 CFR Part , 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 I is limited to the following DOT-regulated testing items, including pre-employment testing results, occurring 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. If any company listed below furnishes 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 previous three (3) years. List all DOT-regulated employers you have applied with and/ or worked for in a safety-sensitive function during the previous three (3) years. If necessary, attach additional pages, including the date, your name, social security number and signature. Previous DOT-Regulated Employer City State Phone Number ( ) - ( ) - ( ) - ( ) - ( ) - ( ) - By signing below, I certify that: (i) all information provided herein is complete and accurate; (ii) I have read and fully understand this Part I 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 the opportunity to ask questions and to have those questions answered to my satisfaction; (iv) I execute this 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 an original. Print Applicant Name: Social Security #: Applicant Signature: : DOT Drug/Alcohol Disclosure/Authorization 4/10 Trucking Industry Employment Purpose

11 Part 2 - FMCSA Notification of Driver Rights In compliance with 49 CFR Part you have certain rights regarding the safety performance history information that will be provided to prospective employers. I) You have the right to review information provided by previous employers. II) You have 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 prospective employers. III) 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. If 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. If 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.

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