Driver's Application for Employment
In compliance with Federal and State equal employment opportunity laws, qualified applicants are considered for all positions without regard to race, color, religion, sex, national origin, age, marital status, veteran status, non-job related disability, or any other protected group status.
TO BE READ AND SIGNED BY APPLICANT
I authorize you to make such investigations and inquiries of my personal, employment, financial or medical history and other related matters as may be necessary in arriving at an employment decision. (Generally, inquiries regarding medical history will be made only if and after a conditional offer of employment has been extended.) I hereby release employers, schools, health care providers and other persons from all liability in responding to inquiries and releasing information in connection with my application.
In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the Company. I understand that information I provide regarding current and/or previous employers may be used, and those employer(s) will be contacted, for the purpose of investigating my safety performance history as required by 49 CFR 391.23(d) and (e). I understand I have the right to:
• Review information provided by previous employers;
• Have errors in the information corrected by previous employers and for those previous employers to re-send the corrected information to the prospective employer; and
▪ Have a rebuttal statement attached to the alleged erroneous information, if the previous employer(s) and I cannot agree on the accuracy of the information.
Termination of Employment
This form is made available with the understanding that J. J. Keller & Associates, Inc. is not engaged in rendering legal, accounting, or other professional services. J. J. Keller & Associates, Inc. assumes no responsibility for the use of this form or any decision made by an employer which may violate local, state or federal law.
Application to Complete
(answer all questions)
If yes, please explain fully on a separate sheet of paper. Conviction of a crime is not an automatic bar to employment - all circumstances will be considered.
All driver applicants to drive in interstate commerce must provide the following information on all employers during the preceding 3 years. List complete mailing address, street number, city, state, and zip code.
Applicants to drive a commercial motor vehicle* in intrastate or interstate commerce shall also provide an additional 7 years' information on those employers for whom the applicant operated such vehicle.
(NOTE: List employers in reverse order starting with the most recent. Add another sheet as necessary.)
1
2
3
4
5
Includes vehicles have a GVWR of 26,001 lbs. or more, vehicles designed to transport 15 or more passengers, or any size vehicle used to transport hazardous materials in a quantity requiring placarding.
The Federal Motor Carrier Safety Regulations (FMCSRs) apply to anyone operating a motor vehicle on a highway in interstate commerce to transport passengers or property when the vehicle: (1) weighs or has a GVWR of 10,001 pounds or more, (2) is designed or used to transport 9 or more passengers, OR (3) is of any size and is used to transport hazardous materials in a quantity.
ACCIDENT RECORD for past 3 years or more (Attach sheet if more space is needed if none, write None.
Nature of Accident
(Head-on, Rear-end, Upset, ect.)
TRAFFIC CONVICTIONS and forfeitures for the past 3 years (other than parking violations) If none, write None.
(Attach sheet if more space is needed)
EXPERIENCE AND QUALIFICATIONS - DRIVER
List all Driver Licenses or permits held in the past 3 years
DRIVING EXPERIENCE
Check that Apply
Which Type of Equipment
(Van, Tank, Flat, Dump, Refer)
Dates
From (M/Y) - To (M/Y)
Approx. No. of Miles (Total)
EXPERIENCE AND QUALIFICATIONS - OTHER
TO BE READ AND SIGNED BY APPLICANT
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.
Candidate: Complete Section 1 ONLY and return with application
SAFETY PERFORMANCE HISTORY RECORDS REQUEST
TO BE COMPLETED BY PROSPECTIVE EMPLOYEE
To release and forward the information requested by section 3 of this document concerning my Alcohol and Controlled Substances Testing records within the previous 3 years from:
This information is being requested in compliance with §40.25(g) and §391.23(h).
Side Section 1: Prospective Employee
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Complete the information required in this section
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Sign and date
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Submit to the Prospective Employer
Side 2 Section 4a: Prospective Employer
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Complete the information
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Send a copy to the Previous Employer
Side 1 Section 2: Previous Employer
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Complete the information required in this section
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Sign and Date
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Complete Side 2 Section 3
Side 2 Section 3: Previous Employer
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Complete the information required in this section
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Sign and date
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Retain a copy
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Return original to Prospective Employer
Side 2 Section 4b: Prospective Employer
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Record receipt of the information
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Retain a copy
PRE-EMPLOYMENT BACKGROUND CHECK DISCLOSURE AND RELEASE
In connection with my application for employment (including contract for services as an independent contractor) with you, I understand that consumer reports which may contain public record information may be requested from a "customer reporting agency" (CRAs). These reports may include the following types of information: names and dates of previous employers, reason for termination of employment, work experience, accidents, and information on drug and alcohol test results and problems, if any. I further understand that such reports may contain public record information concerning my driving records, workers' compensation claims, credit, bankruptcy proceeding, criminal records, ect. from federal, state and other agencies which maintain such records; as well as information from CRAs concerning previous driving record requests made by others from such state agencies, and state provided driving records.
I authorize without any reservation, any party or agency contacted by a CRA to furnish the above mentioned information.
I have the right to make requests to the CRA upon proper identification, to request the nature and substance or 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 the CRA has previously furnished within the two year period preceding my request. I hereby consent to your obtaining the above information from CRA and I agree that such information which CRA has or obtains, and my employment history with you if I am hired, will be supplied by a CRA to other companies that subscribe to a CRA service.
I hereby authorize procurement of consumer report(s). If hired (or contracted), this authorization shall remain on file and shall serve as ongoing authorization for you to procure reports at any time during my employment (or contract) period.
PREVIOUS PRE-EMPLOYMENT EMPLOYEE ALCOHOL AND DRUG TEST STATEMENT
Sec. 40.25(j) As the employer, you must also ask the employee whether he or she has tested positive, or refused to test, on any pre-employment drug or alcohol test administrated by an employer to which the 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 employee admits that he or she had a positive test or a refusal to test, you must not use the employee to perform safety-sensitive function for you, until and unless the employee documents successful completion of the return-to-duty process. (see Sec. 40.25(b)(5) and (e))
The prospective employee is required by Sec. 40.25(j) to respond to the following:
I certify that the information provided on this document is true and correct.
ULLMAN OIL, LLC - MVR CONSENT
In conjunction with my potential employment at Ullman Oil, LLC ("the company"),
I (applicant)
consent to the release of my Motor Vehicle Records (MVR) to the company. I understand the company will use these records to evaluate my suitability to fulfill driving duties that may be related to the position for which I am applying. I also consent to the review, evaluation, and other use of any MVR I may have provide to the company. This consent is given in satisfaction of Public Law 18 USC 2721 et. Seq., "Federal Drivers Privacy Protection Act", and is intended to constitute "written consent" as required by this Act.
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 ULLMAN OIL COMPANY (“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://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. 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 ULLMAN OIL COMPANY (“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. 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.
Driver Candidate, Please Provide Copies of ...
1. CDL
2. Medical Card
3. Social Security Card
4. Other cred./cert.
Thank you for completing this application!
