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.
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
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.
In connection with my application for employment (including contract for services) with you, I understand that consumer reports, which may contain public record information, may be requested from DAC Services,Tulsa, Oklahoma. 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, workers' compensation claims, credit, bankruptcy proceedings, criminal records, etc.,from federal, state and other agencies which maintain such records; as well as information from DAC 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 DAC SERVICES TO FURNISH THE ABOVE-MENTIONED INFORMATION.
I have the right to make a request to DAC, upon proper identification, to request the nature and substance of all information in its files on me at the time of my request, including the sources of information; and the recipients of any reports on me, which DAC has previously furnished within the two year period preceding my request. I hereby consent to your obtaining the above information from DAC, and Iagree that such information, which DAC has or obtains, and my employment history with you if I am hired, will be supplied by DAC to other companies, which subscribe to DAC services.
I hereby authorize procurement of consumer report(s) . If hired (or contracted), this authorization ion shall remain on file and shall serve as ongoing authorization for you to procure consumer reports at any time during my employment (or contract) period.
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: