The purpose of this application is to determine whether or not the applicant is qualified to operate motor carrier equipment according to the requirements of the Federal Motor Carrier Safety Regulations and the Company Named above.

INSTRUCTIONS TO APPLICANT

Please answer all questions. If the answer to any question is “NO” or “NONE”, do not leave the item blank – write “NO” or “NONE”.  THIS IS IMPORTANT!

*The Age Discrimination of Employment Act ofm1967 prohibits discrimination on the basis of age with respect to individuals who are at least 40 but less than 70 years of age.

 

Give a COMPLETE RECORD of all employment for the past three years, including any unemployment or self employment, and all commercial driving experience for the past ten years

TO BE READ AND SIGNED BY APPLICANT

It is agreed and understood that any misrepresentation given on this application for qualification shall be considered an act of dishonesty.

I give the motor carrier and its agents or representatives the right to investigate all references and to secure additional  information  about my employment background. I hereby release from all liability for damages the motor carrier and its agents or representatives for seeking such information and all other persons, corporations or organizations for furnishing such information.

I agree to furnish such additional information and complete such examinations as may be required to complete my employment file. It is agreed and understood that this application for qualification in no way obligates the motor carrier to employ me.

It is agreed and understood that if qualified to operate motor carrier equipment, I may be on a probationary period, during which 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.

 

MANDATORY USE FOR ALL ACCOUNT HOLDERS

IMPORTANT NOTICE

REGARDING BACKGROUND REPORTS FROM THE PSP Online Service

  1. In  connection  with  your  application  for  employment  with  J&L TRANSPORTATION  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).

    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.

    The Prospective Employer cannot obtain background reports from FMCSA unless you consent in writing.

    If you agree that the Prospective Employer may obtain such background reports, please read the following and sign below:

  2. I authorize J&L TRANSPORTATION 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 consenting to 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.
  3. 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 l may challenge the accuracy of the data by submitting a request to https://dataqs. fmcsa.dot.gov. If I am challenging 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.
  4. Please note: 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 FMCSR violations that have been adjudicated by a court of law will also appear, and remain, on a PSP report.

I have read the above Notice Regarding Background Reports provided to me by Prospective Employer and I understand that if I sign this consent form, 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 NICT 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 hold ers are required by FMCSA to use the language provided in paragraphs 1-4 of this document to obtain an Applicant’s consent. The language must be used in whole, exactly as provided . The language may be included with other consent forms or language at the discretion of the account holder, provided  the four paragraphs  remain  intact and  the language is unchanged.