NOTICE TO ALL DRIVERS CERTIFICATE OF COMPLIANCE
I. NOTICE TO ALL DRIVERS
The Commercial Motor Vehicle Act of 1986 provides for a new set of controls over the drivers of commercial vehicles. The new law applies to all drivers operating vehicles and combinations with a Gross Vehicle Weight Rating over 26,000 pounds, and to any vehicle, regardless of weight, transporting hazardous materials.
The following provisions of this legislation became effective July 1, 1987:
1. No driver may possess more than one license, and no motor carrier may use a driver having more than one license. A limited exception is made for drivers who are subject to non-resident licensing requirements of any state. This exception does not apply after December 31, 1989.
2. A driver convicted of a traffic violation (other than parking) must notify the motor carrier and the state which issued the license to that driver of such conviction within 30 days.
3. Any person applying for a contract position as a commercial vehicle driver must inform the prospective carrier of all previous employment as the driver of a commercial vehicle for the past ten years, in addition to any other required information about the applicant's employment history.
4. Any violation is punishable by a fine not to exceed $2,500.00. In addition, the Federal Motor Carrier Safety Regulations now require that a driver who loses any privilege to operate a commercial vehicle or who is disqualified from operating a commercial vehicle, must advise the motor carrier the next business day after receiving notification of such action.
TO BE RETAINED BY MOTOR CARRIER II. CERTIFICATION BY DRIVER. I hereby certify that I have read and understand the driver provisions of the Commercial Motor Vehicle Safety Act of 1986 which became effective on July 1, 1987.
DRIVER'S LICENSE List driver's license numbers for each state of all driver's licenses held in the past three years:
How many driver's licenses have you held in the past three years? *
(list the details for each one below)
Number of years and months of commercial tractor-trailer driving experience while licensed as a Class-A CDL driver
Driver Application - INDEPENDENT CONTRACTOR DRIVER APPLICATION
Public Law 91-506 requires that an applicant be advised that a routine inquiry may be made which will provide valid information concerning character, general reputation, personal characteristics and mode of living. Upon written request additional information as to nature and scope of the report if one is made will be provided. Where relevant, information in this application will be used and prior employers will be contacted for purposes of investigation as required by 391-23 of the Motor Carrier Safety Regulation.
To Be Read and Signed by Applicant: I hereby authorize my former employers to provide any and all information regarding my employment and any other interaction with them. I understand that I may be asked to demonstrate that I am capable of performing tasks associated with the position applied for. I agree and understand that my background may be investigated for any and all information of concern to my record. My name below indicates 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.
Total Years of Past Experience *
Please click the Add New Employer to enter your Past Employment History.
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 ("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 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 ("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.
PAST EMPLOYMENT VERIFICATION
|
Send To:
|
Return Address:
|
Please Fax Back To: ___________________________
|
Fax No.:__________________________________
|
Telephone No.:_________________________________
|
Previous Employer: _______________________________________________________________ MC#:_______________________
Phone: ________________________________________ Fax:________________________________ E-mail:______________________________________
|
Applicant Name:
|
Position Applied For:
|
Applicant states that he/she was in your employ as a:_________________________
|
From: ___/___/______ to ___/___/______
|
Applicant’s job title:
|
Actual dates of employment: ___/___/______ to ___/___/______
|
Reason for leaving your employ: Laid off____Discharged____Quit____
|
Eligible for re-hire: Yes____No____
|
Drove a tractor-trailer: Yes____No____
|
Solo ____ or team ____
|
Full time: Yes____No____
|
Local______ Regional_______ OTR_______
|
Length of Trailer: _______________ft.
|
Number of accidents _______
|
Number of preventables _______
|
Any serious/major accidents Yes____No____
|
If so, please describe:____________________________________________________________________
|
Any disciplinary problems: Yes______ No_______
|
Ever been placed out of service due to H.O.S. (CFR Part 395): Yes____No____ If yes please explain below:
|
Was applicant’s license suspended or revoked while employed? Yes____No____ If yes please explain below:
|
Has applicant been subject to DOT required drug or alcohol testing in the past three years? Yes _____ No _____
|
If yes when ____/____/______
|
Has this applicant tested positive in the past three years? Yes _____ No _____ If yes when ___/___/_____
|
Has this applicant refused to take a DOT drug or alcohol test in the past three years? If yes when ___/___/_____
|
If tested positive was the applicant referred to a Substance Abuse Professional for treatment? Yes_____No_____
|
If yes please provide the name, address and phone number of this professional:
|
Did the applicant refuse treatment? Yes ____ No____
|
Any other violations of the US DOT drug and alcohol rules? Yes ____No____ If yes please explain below:
|
This form was completed by:
|
Title:
|
Date: ___/___/___
|
Response provided by:
|
Title:
|
Date: ___/___/___
|
Pursuant to sections 604 and 607 of the fair credit reporting act (FCRA) P.L. 91-508, and in regard to my application for contracted services, I hereby authorize and/or allow the release of any and all information, on an as needed basis per Title 49 of the Code of Federal Regulations. I hereby authorize/allow , my previous employers, insurance companies, health care providers, educational institutions, law enforcement/state agencies or references to release any and all information necessary for the purposes of conducting an investigation as required by 49CFR 391.23 and to obtain the drug/alcohol test result information as required by 49CFR 382.405 (£) and 49CFR 382.413 of The Regulations. I authorize without reservation or time limit any employer party or agency contacted by this company or other information provider to furnish the above-mentioned information. You and or your company are released from all liability which may result from furnishing any of the above information.
|
Applicant’s Signature______________________________________________________________________________SS# ______________________________________________ Date:______/______/____________
|
Employee Verification Form
Disclaimer: Pursuant to sections 604 and 607 of the Fair Credit Reporting Act (FCRA 15 U.S.C. 1681 b,e), P.I. 91-508, and in regard to my application for driver/contracted services, I hereby authorize and/or allow the release of any and all information, on an as needed basis per Title 49 of the Code of Federal Regulations, including, but not limited to a “Driver’s” driving record/MVR/Abstract. I hereby authorize/allow , my previous employers, insurance companies, health care providers, educational institutions, law enforcement/state agencies, or references to release any and all information necessary for the purposes of conducting an investigation as required by 49CFR 391.23, and to obtain the Drug/Alcohol Test result information (per 49 CFR 382.401) as required by 49CFR 382.405 (f) and 49CFR 382.413 of the regulations. I authorize, without reservation or time limit, any employer, party or agency contacted by this company or other information provider to furnish the above mentioned information. You and or your company are released from all liability which may result from furnishing any of the above information.
My signature certifies that this application was completed by me, and all entries on it and information in it are true and complete to the best of my knowledge pursuant to Part 391.21 (b) (12).
By selecting the “submit” button, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your hand written/manual signature.
Printed Name *
|
Redirecting to E-Signature Page. Please Wait......
|
|