Driver Application

In case of emergency, notify:

The following information is required by the U.S. Department of Transportation, Section 391.21. Your application will not be considered if all information is not furnished.

PREVIOUS RESIDENCY:

Please furnish the addresses at which you resided during the 3 years preceding the date on which the application is submitted.

BEGIN WITH THE MOST RECENT

COMMERCIAL MOTOR VEHICLE OPERATOR’S LICENSE

Please furnish the issuing State, number, and expiration of each unexpired commercial motor vehicle operator’s license or permit that has been issued to you in the lines provided below.

EMPLOYMENT RECORD

The U.S. Department of Transportation requires that driver applicants show all employment for the past three years. Effective July 1987, applicants must show all commercial driver employment for the seven years immediately preceding this three year period. 391.21 (b) (10)(11)

Authorization

I authorize Vette City Transportation, LLC. to obtain information about me from my previous employers, schools and credit sources. I authorize my previous employers, schools that I have attended and all credit sources to disclose to Vette City Transportation, LLC. such information about me as Vette City Transportation, LLC. may request.

PAST EXPERIENCE

NOTICE TO APPLICANT

1. All information submitted will be considered in reviewing my application and is subject to investigation. I hereby authorize Vette City Transportation, LLC. to investigate all statements applicable, except as indicated.
2. I certify that the facts set forth in this employment application are true and complete to the best of my knowledge. I understand that misrepresentation or omission of facts called for is cause for dismissal upon discovery of such information.
3. If accepted for employment, I hereby agree to comply with the rules, regulations and policies of Vette City Transportation, LLC.
4. I am aware that an investigative consumer report may be made in connection with my application for employment. This report may include information as to my character, general reputation, personal habits, and mode of living, obtained from or through personal interview with persons with whom I am acquainted, or those persons who may have knowledge concerning any such items of information.
5. In the event that such an investigative consumer report is procured, upon my written request for Vette City Transportation, LLC., I will be provided with a complete and accurate disclosure of the nature and scope of the investigation conducted.
6. I understand that Vette City Transportation, LLC. follows an employment-at-will policy, in that I or Vette City Transporation, LLC. may terminate my employment at any time, for any reason consistent with applicable State or Federal Law.

PRE-EMPLOYMENT SUBSTANCE DETECTION CONSENT

I understand that according to the Pre-employment Substance Detection Program at Vette City Transportation, LLC., I am required to submit a sample of my urine for chemical analysis prior to employment. I understand that this pre-employment substance detection will be conducted be a reputable outside physician and testing agency by a certified laboratory.

I consent freely and voluntarily to this request for a pre-employment urine specimen. I hereby and herewith release Vette City Transportation, LLC., their employees, agents, and contractors from any liability whatsoever arising from this request to furnish a pre-employment urine sample, the testing of the urine sample and decisions made concerning my application for employment or continued employment based upon the results of these tests.

I understand a positive test for controlled substances, based on the urinalysis test, will disqualify me from employment and/or the operation of a commercial motor vehicle for Vette City Transportation, LLC.

I understand that if the substance detection results are positive, I can request a second independent confirmatory test using the same specimen. The cost of this test will be borne by me.

I understand a documented chain of specimen custody exists to ensure the identity and integrity of my sample throughout the collection and testing process. The Medical Review Officer will maintain the results of the urinalysis test. Negative and positive results will be reported to the company.

I understand that if my employment is terminated for any reason with Vette City Transportation, LLC. within 90 days, I am liable for the cost of the urinalysis, which is $50.00.

I have read and understood the above Notice to the Applicant and the conditions for the Pre-Employment Urinalysis Consent Agreement.

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 Vette City Transportation, LLC (“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://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 Vette City Transportation, LLC (“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://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.

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 12/22/2015