Application Form

Please complete this application in its entirety for proper consideration for employment

You are currently applying for the company .

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Step 1 of 6

Your Personal Information

PLEASE ANSWER ALL QUESTIONS. IF THE ANSWER TO ANY QUESTION IS "NO" OR "NONE", DO NOT LEAVE THE ITEM BLANK, BUT WRITE "NO" OR "NONE".

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Company name

First Name*

Middle

Last Name*

Date of Birth*

Social Security*

Email*

Address*

City*

State*

Zip*

Mobile Phone Number*

Do not use parentheses or dashes

Driver's License Number*

State of Issue*

Class*

Driver License Issue Date*

Driver License Expiration Date*

Endorsements*

Other Endoresement*

Driver's License Front Image*

Accepted file types: jpg, jpeg, gif, png, pdf, Max. file size: 8 MB.

Driver's License Back Image*

Accepted file types: jpg, jpeg, gif, png, pdf, Max. file size: 8 MB.

Employment History

List previous employment during the last ten years and account for gaps between employers (383.35) If owner/operator, list the carriers to whom you leased.

Employment History

Employer*

Start Date*

End Date*

Supervisor*

Phone*

Email Address

Address*

City*

State*

Zip*

Were you subject to the Federal Motor Carrier Safety Regulations during this period?*

Were you subject to 49 CFR part 40 controlled substance and alcohol testing during this period?*

Reason for Leaving*

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CERTIFICATION

It is agreed and understood that any misrepresentation given on this document shall be considered an act of dishonesty. It is agreed and understood that the motor carrier on his agents may investigate my background to ascertain any and all information of concern to commercial driving record, whether same is of record or not, and I release the employers and persons named herein from all liability for any damages on an account of their fumishing such information. It is also agreed and understood that under the Fair Credit Reporting Act, Public Law 91-508, 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 certify that this application was copmpleted by me, and that all entries on it and information in it are true and complete to the best of my knowledge."

Applicant's Signature*

Date Signed*

DRIVER'S RIGHTS PERTAINING TO RELEASE OF DRIVER INFORMATION UNDER 49 CFR 391.23

Motor carriers have the responsibility to make the following investigations and inquiries and maintain records of such investigations and inquiries in the Driver Qualification File (DQF) for 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, 1971.

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
An investigation of the driver's employment record during the preceding three years.
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 DQF within 30 days of the date the driver's employment begins and be retained in compliance with 391.51.
Replies to the investigations of the driver's safety performance history must be placed in the DQF within 30 days of the date the driver's employment begins.
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 390.15 for accident involving the driver that occurred in the three-year period preceding the date to the employment application, and any accidents the previous employer may wish to provide.
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 49CFR Part 40.
Prospective motor carrier must perform a pre-employment query in the FMCSA drug and alcohol clearinghouse under part 382.701.

Drivers have the following rights:

The right to review information provided by previous employers.
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.
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.
The right to petition FMCSA contesting the accuracy of information in the Clearinghouse in accordance with Part 382.717

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 drivers Safety Performance History.

I acknowledge that I have read and understand the contents of this document.

Driver's Signature*

Date Signed*

CLEARINGHOUSE AUTH FOR LIMITED QUERIES

I, {applicant}, hereby provide consent to to conduct limited queries 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 authorization remains in effect until my employment with terminates or until I revoke such consent in writing. I understand that my employer may conduct limited queries on the Clearinghouse as many times as they deem necessary or is required by Federal regulations. I understand that if the limited query conducted by indicates that drug or alcohol violation information about me exists in the Clearinghouse, FMCSA will not disclose that information without first obtaining additional specific consent from me which will require me to login to the Clearinghouse and provide consent for a full query containing detailed information about any violations that may appear on my record. I further understand that if I refuse to provide consent to conduct limited queries of the Clearinghouse, must prohibit me from performing safety-sensitive functions, including driving a commercial motor vehicle, as required by FMCSA’s drug and alcohol program regulations.

Driver's Signature*

Date Signed*

Company Substance Free Workplace Policy

Click here to view or download the company substance Free Workplace Policy.

Have you failed or refused a DOT drug or alcohol pre-employment test within the past 3 years from an employer who did not hire you?*

Yes

I certify that I have read, understand, and am in receipt of a copy of the company’s Drug and Alcohol Abuse Policy for Employees linked above. I am required to possess a Commercial Driver’s License and that I am registered in the FMCSA Clearinghouse and that there is no restriction on my clearance to immediately perform FMCSA Safety Sensitive duties as a DOT regulated Driver. I understand that false or misleading information given in my application for employment may result in discharge.

Driver's Signature*

Date Signed*

Request for Driving and PSP Records

I hereby authorize you to release the following information to for purposes of investigation as required by Sections 391.23 and 391.25 of the Federal Motor Carrier Safety Regulations. You are released from any and all liability, which may result from furnishing such information.

Name as it appears on the drivers license*

Current Adress*

City*

State*

Zip*

Former Adress

City

State

Zip

License Number*

State of Issue*

Date Of Birth*

IMPORTANT DISCLOSURE

REGARDING BACKGROUND REPORTS FROM THE PSP Online Service

In connection with your application for employment with , 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 DataQ’s 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 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.

In accordance with the provisions of Section 604 and 607 of the Fair Credit Reporting Act Public Law 91-508, I hereby certify the following:

The applicant has authorized in writing the procurement of this report;
The information requested below will be used for a "permissible purpose" (i.e., information for employment purposes) and will be used for no other purpose;
The information being obtained will not be used in violation of any federal or state equal employment opportunity law or regulation; and
Before taking adverse action based in whole or in part on the report; the applicant will receive a copy of the requested report.

I also hereby certify that this report request and the above applicant's release notice meet the definition of "permissible uses" of state motor vehicle records under the provisions of the Driver's Privacy Protection Act of 1994.

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 Proch now Transport Inc ("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).

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.

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 Prochnow Transport Inc (•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.

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.

Signature*

Date Signed*

Application Form

Please complete this application in its entirety for proper consideration for employment

You are currently applying for the company .

Your Personal Information

ADDITIONAL ADRESSES

Educational History

Driving Experince

Employment History

CERTIFICATION

DRIVER'S RIGHTS PERTAINING TO RELEASE OF DRIVER INFORMATION UNDER 49 CFR 391.23

Drivers have the following rights:

CLEARINGHOUSE AUTH FOR LIMITED QUERIES

Company Substance Free Workplace Policy

Request for Driving and PSP Records

IMPORTANT DISCLOSURE

REGARDING BACKGROUND REPORTS FROM THE PSP Online Service

AUTHORIZATION

THE BELOW DISCLOSURE AND AUTHORIZATION LANGUAGE IS FOR MANDATORY USE BY ALL ACCOUNT HOLDERS