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1 Step 1

1. To Be Read and Signed By Applicant


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.


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.


This certified that this application was completed by me, and that all entries on it and information in it is true and complete to the best of my knowledge.


"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 that I have the right to:


  • Review information provided by current/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
  • 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."

By signing in the space below you have read, understand and agree to the above terms and conditions.

SignatureType your name in full (this is your electronic signature).
PrefixJr., Sr., III
DateToday's Date

2. Employment Application

First Name
Last Name
Prefix
Social Security Number
Date of Birth
Phone
Address
APT/Suite #
City
Zip
Number of Years at Present Address
1+
0
4+

Please provide your tractor information:
Make
Model
Year

3. Employment History

All applicants wishing to drive in interstate commerce must provide the following information on all employers during the preceding three years. You must give the same information for all employers for whom you have driven a commercial vehicle seven years prior to the initial three years (total of ten year employment record).

(Use Additional Employment History Information form if necessary)


You are required to list the complete mailing address: street number and name, city, state and zip code.

Current or Last Employer
Phone
Fax
Address
Suite #
City
Zip
Position Held
From
To
Reason for LeavingPlease explain in detail
0 /
Were you subject to the FMCSRs** while employed?

** 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 requiring placarding.

Was your job designated as a safe-sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40?
Account for Period Between Jobs - Include dates (month/year) and reasonAny gaps in employment and/or unemployment must be explained.
0 /

Need to Add Additional Employment History Information?

3b. Employment History

Second Employer
Phone
Fax
Address
Suite #
City
Zip
Position Held
From
To
Reason for LeavingPlease explain in detail
0 /
Were you subject to the FMCSRs** while employed?
Was your job designated as a safe-sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40?

Need to Add A 3rd Employer?

3c. Employment History

Third Employer
Phone
Fax
Address
Suite #
City
Zip
To
Position Held
From
Reason for LeavingPlease explain in detail
0 /
Were you subject to the FMCSRs** while employed?
Was your job designated as a safe-sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40?

4. Driving Experience

Do you have Driving Experience within the past 3 years?

Straight Truck Experience?
Straight Truck Experience Type(check all that apply)
From
To
Approximate Miles Driven

Tractor & Semi Trailer Experience?
Tractor & Semi Trailer Experience Type(check all that apply)
From
To
Approximate Miles Driven

Two Trailers - Tractor Experience?
Two Trailers - Tractor Experience Type(check all that apply)
From
To
Approximate Miles Driven

Three Trailers - Tractor Experience?
Three Trailers - Tractor Experience Type(check all that apply)
From
To
Approximate Miles Driven

Motorcoach School Bus (Greater than 8 Passengers)?
Motorcoach School Bus (Greater than 8 Passengers) Experience Type(check all that apply)
From
To
Approximate Miles Driven

Motorcoach School Bus (Greater than 15 Passengers)?
Motorcoach School Bus (Greater than 15 Passengers) Experience Type(check all that apply)
From
To
Approximate Miles Driven

Equ Class - Other
Other Name
Equ Class - Other Experience Type(check all that apply)
From
To
Approximate Miles Driven

5. Accident History

Have you had any accidents in the last 3 years?
Accident Dateof appointment
Hazardous Materials Spilled?
Number of Injuries
Number of Fatalities
Nature of Accident(head-on, rear-end, upset, etc.)
0 /

Have another accident?
Please explain your second accident(head-on, rear-end, upset, etc.)
0 /

6. Traffic Citations/Forfeitures

Have you had any traffic citations and/or forfeitures in the last 3 years?
Citation/Forfeiture Date
Violation (other than parking)
Penalty(forfeited bond, collateral and/or points)
Have another citation/forfeiture?
Please explain your second citation/forfeiture
0 /

7. License Information

Section 383.21 FMCSR states "No person who operates a commercial motor vehicle shall at any time have more than one driver's license." I certify that I do not have more than one motor vehicle license, and that my driver's license information is listed below.

License Number
Expiration Date
Have you ever been denied a license, permit, or privilege to operate a motor vehicle?
Please give details
0 /
Has any license, permit, or privilege ever been revoked?
Please give details
0 /

8. Applicant Certification

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.

SignatureType your name in full (this is your electronic signature).
PrefixJr., Sr., III
DateToday's Date

9. Disclosure Regarding Background Information

CFR AutoDirect (the "Company") may request, for lawful employment purposes, background information about you from a consumer reporting agency in connection with your employment or application for employment (including independent contractor assignments, as applicable). This background information may be obtained in the form of consumer reports and/or investigative consumer reports (commonly known as "background reports"). These background reports may be obtained at any time after receipt of your authorization and, if you are hired or engaged by the Company, throughout your employment or your contract period.


The types of information that may be obtained include, but are not limited to: social security number verifications; address history; credit reports and history; criminal records and history; public court records; driving records; accident history; worker's compensation claims; bankruptcy filings; educational history verifications (e.g., dates of attendance, degrees obtained); employment history verifications (e.g., dates of employment, salary information, reasons for termination, etc.); personal and professional references checks; professional licensing and certification checks; drug/alcohol testing results, and drug/alcohol history in violation of law and/or company policy; and other information bearing on your character, general reputation, personal characteristics, mode of living and credit standing.


I also accept the IMPORTANT NOTICE REGARDING BACKGROUND REPORTS FROM THE PSP Online Service, which reads:


  • In connection with your application for employment with CFR AutoDirect (“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:
  • I authorize CFR AutoDirect (“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.
  • 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 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.
  • 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.

My signatures have been added electronically for each section above.

First Name
Last Name
Prefix
SignatureType your name in full (this is your electronic signature).
DateToday's Date

10. FMCSA Records Access

In connection with your application for employment with CFR AutoDirect (“Prospective Employer”), it may obtain one or more reports regarding your driving, and safety inspection history from the Federal Motor Carrier Safety Administration (FMCSA). 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. 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: I authorize CFR AutoDirect (“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. 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://Iatags.fincsa.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. I have read the above Notice Regarding Background Reports provided to me by Prospective Employer and 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.

SignatureType your name in full (this is your electronic signature).
DateToday's Date

Submitting Your Application

Please take a moment to verify all of your information is correct. Once the "Submit Application button is clicked, no changes can be made.

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