FIRST CHOICE OF ELKHART, INC PRELIMINARY DRIVER APPLICATION THANK YOU FOR YOUR INTEREST! PLEASE COMPLETE ALL INCLUDED FORMS AND RETURN TO FIRST CHOICE ALONG WITH A COPY OF YOUR CLASS A CDL. PLEASE NOTE THAT THE APPLICATION PROCESS CANNOT PROCEED UNTIL THE PRELIMINARY APPLICATION IS COMPLETED IN FULL. In Compliance with Federal and State equal opportunity laws, qualified applicants are considered for all positions without regard to race, color, religion, sex, national origin, age, marital status, or non-job related disability. 1 Revised: February 2016
First Choice of Elkhart, Inc. 10888 US Hwy 12 White Pigeon, MI 49099 P: 269-483-2010 F: 269-483-2710 Today s Date: Date of Birth: Social Security #: 1. NAME: LAST FIRST MIDDLE 2. ADDRESS: STREET CITY STATE ZIP 3. HOME PHONE: CELL PHONE: 4. LENTH OF TIME AT CURRENT ADDRESS: 5. Please list your previous addresses of residency for the past 3 years if different from current address. ADDRESS: STREET CITY STATE ZIP LENGTH OF TIME ADDRESS: STREET CITY STATE ZIP LENGTH OF TIME 6. Please provide your Experience in years for the following types of Equipment. TYPE (i.e.: Straight Truck, Van, Flat, Car, etc.) FROM TO PERSONAL BIOGRAPHY 391.21 2
7. Please provide details for all TRAFFIC VIOLATIONS for the previous 3 years. DATE LOCATION CHARGE TYPE OF VEHICLE 8. Please provide all details for any ACCIDENTS for the previous 3 years. DATE DESCRIPTION INJURIES/FATALITIES TYPE OF VEHICLE 9. Please provide information for ANY DRIVERS LICENSES HELD for the previous 3 years. STATE LICENSE # EXPIRATION DATE 10. Has your license ever been suspended or revoked? If yes, when? For what reason? 11. Have you ever been convicted of a felony? If yes, date and nature of offense 12. Please list all schools, courses or training related to trucking that you have attended. 13. Circle the highest education level you have completed. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 GED 14. Are you a United States Citizen? If no, do you have a valid green card? 15. Have you ever served in the Armed Forces? If yes, did you receive an honorable discharge? 16. List all states operated in during the last three years. PERSONAL BIOGRAPHY 391.21 3
Previous Employment List all employment during the last 3 years, plus all driving experience the 7 years prior to the initial 3. There should be a total of 10 years of previous employment listed. You may use additional sheets if necessary. PREVIOUS EMPLOYMENT 391.21 4
TO BE READ AND SIGNED BY APPLICANT This certifies that I completed this application, and that all entries, and information documented by me are true and complete to the best of my knowledge. By my signature heretofore, I acknowledge having been offered by this carrier, which has presented me with this application, a statement of my right to due process as outlined by all parts of 49 CFR Part 391.23 of the Federal Motor Carrier Safety Regulations effective October 29, 2004. Having made this acknowledgment, I therefore authorize you to make such previous employment and background investigations and inquiries of my personal, employment, financial or medical history, and other related matters as may be necessary to arrive at a possible decision. (Generally, inquiries regarding medical history will be made only if and after a conditional offer of employment or contracted services has been extended.) I understand that false or misleading information given in my application or interviews may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the company. Applicant s Signature Date APPLICATION ACKNOWLEDGMENT & RELEASE 391.23 5
Sec. 40.25(j) As the carrier, we must also ask the prospective contractor whether he or she has tested positive or refused to test on any pre-lease or pre-employment drug or alcohol test administered by a carrier or an employer to which the contractor/employee applied for but did not obtain safety-sensitive transportation work covered by DOT agency drug and alcohol testing rules during the past two years. If the contractor admits that he or she had a positive test or a refusal to test, we must not use the contractor to perform safety sensitive functions until and unless the contractor documents successful completion of the return-to-duty process (see Sec. 40.25(b) (5) and (e). First Choice of Elkhart, Inc. 10888 US 12 White Pigeon, MI 49099 Prospective Driver Name (print) Social Security No. The prospective contractor is required by Sec. 40.25 (j) to respond to the following questions: 1) Have you tested positive, or refused to test, on any pre-employment/pre-lease drug or alcohol test administered by an employer or carrier to which you applied for but did not obtain safety-sensitive transportation work covered by DOT agency drug and alcohol testing rules during the past two years? Yes No 2) If you answered yes, can you provide/obtain proof that you have successfully completed the DOT return to duty requirements? Yes No Prospective Driver Signature Date Witnessed By (signature) Date PRE-LEASE CONTRACTOR ALCOHOL AND DRUG TEST STATEMENT 6
In connection with my application for employment, including contract for services with you, I understand that consumer reports, which may obtain public record information, may be requested from any previous employer or any agency that obtains information from public records. These reports may include the following types of information: names and dates of previous employers, reason for termination of employment, work experience, accidents, etc. I further understand that such reports may contain public record information concerning my driving record, worker s compensation claims, credit, bankruptcy proceedings, criminal records, etc., from federal, state and other agencies which maintain such records; as well as information from any previous employer, or any agency who obtains information from public records concerning previous driving record requests made by others from such state agencies, and state provided driving records. I authorize without reservation, any party or agency contacted by First Choice of Elkhart, or their authorized representative, to furnish the above mentioned information. I have a right to make a request to First Choice of Elkhart, or their authorized representative, upon proper identification, the nature and substance of all information in its files on me at the time of my request to First Choice of Elkhart, or their authorized representative, which was previously furnished within the two-year period preceding my request. I hereby consent to you obtaining the above information from any previous employer or any agency who obtains information from public records. I hereby authorize procurement of consumer report(s). If hired or contracted, this authorization shall remain on file and serve as ongoing authorization for you to procure consumer reports at any time during my employment or contract duration. Print Name Social Security Number Driver Signature Date FAIR CREDIT REPORTING ACT DISCLOSURE AND RELEASE 7
In the interest of maintaining the safety and security of our customers, employees and property, First Choice of Elkhart, Inc. (the ) will order a consumer report (a background report) or investigative consumer report on you in connection with your application. Furthermore, if you are contracted through the, or if you already work for First Choice, we may order additional background reports on you for employment and review purposes. The background check company, ADP Screening and Selection Services, with prepare the background report for the. ADP Screening and Selection Services is located at 301 Remington Street, Fort Collins, CO 80524, and can be reached by phone at 800-367-5933 or online via www.adpselect.com. The background report may contain information concerning your character, general reputation, personal characteristics, mode of living, and credit standing. The types of information that may be ordered include but are not limited to: Social Security number verification, criminal, public, educational and, as appropriate, driving records checks, verification of prior employment, reference, licensing and certification checks, credit reports, drug testing results; and, if applicable, worker s compensation injuries. Worker s compensation information will only be requested in compliance with the Americans with Disabilities Act and/or any other applicable federal, state or local laws and only after a conditional job offer has been made. Credit history will only be requested when permitted by law and where such information is substantially related to the duties and responsibilities of the position for which you are applying. The information may be obtained from private and public record sources, including personal interviews with your associates, friends and neighbors. An investigative consumer report is a background report that includes information from such personal interviews, except in California where that term means any background report that is not a credit report. The nature and scope of the most common form of investigative consumer report is an investigation into your education and/or employment history conducted by ADP Screening and Selection Services or another outside organization. You may request more information about the nature and scope of an investigative consumer report by calling the at 269-483-2010. A summary of your rights under the Fair Credit Reporting Act can be provided at your request. The Fair Credit Reporting Act gives you specific rights in dealing with consumer reporting agencies. You will find these rights summarized on A Summary of Your Rights Under the Fair Credit Reporting Act and A Summary of Your Rights Under the California Civil Code Section 1786.22 which will be provided upon request. State Law Notices If you live or work for the in the states listed below, please note the following: CALIFORNIA: You may view the file that ADP Screening and Selection Services has for you, and order a copy of the file, upon submitting proper identification and paying copying costs, by coming to their offices, during normal business hours and on reasonable notice, or by mail. You may also ask for a file-summary by telephone. ADP Screening and Selection Services can answer questions about information in your file, including any coded information. If you come in person, another person can come with you, so long as that person can show proper identification. MAINE: If you ask us, you have the right to know whether the ordered an investigative consumer report on you. You may request the name, address, and telephone number of the nearest office for ADP Screening and Selection Services. You will get this information within 5 business days of our receipt of your request. You have the right to ask ADP Screening and Selection Services for a free copy of the report. MARYLAND: If the obtains credit history information on you, it will be used to evaluate whether you would present an unacceptable risk of theft or other dishonest behavior in the job for which you are being considered. MASSACHUSETTS/NEW JERSEY: If you submit a request to us in writing, you have the right to know whether the ordered an investigative consumer report from ADP Screening and Selection Services. You may inspect and order a free copy of the report by contacting ADP Screening and Selection Services. MINNESOTA: If you submit a request to us in writing, you have the right to get from the a complete and accurate disclosure of the nature and scope of the consumer report or investigative consumer report ordered, if any. NEW YORK: If you submit a request to us in writing, you have the right to know whether the ordered a consumer report or an investigative consumer report from ADP Screening and Selection Services, and you will be provided with the name and address of ADP Screening and Selection Services. You may inspect and order a free copy of the reports by contacting ADP Screening and Selection Services. A copy of Article 23A of the New York Correction Law is being provided with this form. OREGON: If the obtains credit history information on you, it will be used to evaluate whether you would present an unacceptable risk of theft or other dishonest behavior in the job for which you are being considered. WASHINGTON STATE: If you submit a request to us in writing, you have the right to get from the a complete and accurate disclosure of the nature and scope of the investigative consumer report we ordered, if any. You also have the right to ask ADP Screening and Selection Services for a written summary of your rights under the Washington Fair Credit Reporting Act. If the obtains information bearing on your credit worthiness, credit standing or credit capacity, it will be used to evaluate whether you would present an unacceptable risk of theft or other dishonest behavior in the job for which you are being considered. BACKGROUND CHECK DISCLOSURE AND AUTHORIZATION FORM 8
After carefully reading the Background Check Disclosure and Authorization form, I authorize the to order my background report, including investigative consumer reports. I understand that the may rely on this authorization to order additional background reports, including investigative consumer reports, during my employment without asking me for my authorization again as allowed by law. I also authorize the following agencies and entities to disclose to ADP Screening and Selection Services and its agents all information about or concerning me, including but not limited to: my past or present employers; learning institutions, including colleges and universities; law enforcement and all other federal, state and local agencies; federal, state and local courts; the military; credit bureaus; testing facilities; motor vehicle records agencies; all other private and public sector repositories of information; and any other person, organization, or agency with any information about or concerning me. The information that can be disclosed to ADP Screening and Selection Services and its agents includes, but is not limited to, information concerning my employment history, earnings history, education, credit history, motor vehicle history, criminal history, military service, professional credentials and licenses and substance abuse testing. I agree the may rely on this authorization to order background reports, including investigative consumer reports, from companies other than ADP Screening and Selection Services without asking me for my authorization again as allowed by law. I also agree that a copy of this form is valid like the signed original. I certify that all of my personal information on this form is true and correct and understand that dishonesty will disqualify me from consideration for employment with the, or if I am hired or already work for the, that my employment may be terminated. Last Name First Middle Maiden/Other Names Years Used Social Security Number Driver s License Number State FOR IDENTIFICATION PURPOSES ONLY: Date of Birth / / (Month/Day/Year) ADDRESSES WITHIN THE PAST 7 YEARS (use a separate sheet as needed) Present Street City/State/ZIP Prior Street City/State/ZIP From / / (Month/Day/Year) To / / (Month/Day/Year) Prior Street City/State/ZIP From / / (Month/Day/Year) To / / (Month/Day/Year) Signature / / Date: mm/dd/yyyy If you live or work for the in California, Minnesota or Oklahoma: Check this box if you would like a free copy of your background check report: AUTHORIZATION FOR BACKGROUND CHECKS 9