Elementor #867

Application form

Full application form

Step 1 of 14

Applicant Name*
First Last
Date of Application*
MM slash DD slash YYYY
Email*
Phone*
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.
Signature (Full name):*

Position applied for:*

CMC Driver
Social Security Number*
Your SSN should have maximum 9 numbers (ex. 112223344)
List your addresses of residency for the past 3 years.*
Street Address City State / Province / Region ZIP / Postal Code Country
Previous Addresses (if you have):
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Previous Addresses (if you have):
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

EMPLOYMENT HISTORY All driver applicants to drive in interstate commerce must provide the following information on all employers during the preceeding 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.)
Employer name:*
Address*
Street Address City State / Province / Region ZIP / Postal Code Country
Date: From:*
MM slash DD slash YYYY
Date: To:*
MM slash DD slash YYYY
Salary/Wage:*
Position held:*
REASON FOR LEAVING:*
WERE YOU SUBJECT TO THE FMCSRs WHILE EMPLOYED?*
Yes
No
WAS YOUR JOB DESIGNATED AS A SAFETY-SENSITIVE FUNCTION IN ANY DOT-REGULATED MODE SUBJECT TO THE DRUG AND ALCOHOL TESTING REQUIREMENTS OF 49 CFR PART 40?*
Yes
No

EMPLOYMENT HISTORY
Continued/Optional(Leave empty if you fulfill your full employment history and proceed to next page).
Continued Employment History
Yes, I have
No, I don't have
Employer name:*

Address*
Street Address City State / Province / Region ZIP / Postal Code Country

Date: From:*
MM slash DD slash YYYY

Date: To:*
MM slash DD slash YYYY

Salary/Wage:*

Position held:*

REASON FOR LEAVING:*

WERE YOU SUBJECT TO THE FMCSRs WHILE EMPLOYED?*
Yes
No
WAS YOUR JOB DESIGNATED AS A SAFETY-SENSITIVE FUNCTION IN ANY DOT-REGULATED MODE SUBJECT TO THE DRUG AND ALCOHOL TESTING REQUIREMENTS OF 49 CFR PART 40?*
Yes
No

Have you ever been denied a license, permit or privilege to operate a motor vehicle?*
Yes
No
Has your driver's license, permit, or privilege been suspended or revoked?*
Yes
No
Have you ever been disqualified from driving a motor vehicle under D.O.T regulations?*
Yes
No
Have you ever been convicted for possession, sale or use of narcotic drugs, amphetamines, or a derivative?*
Yes
No
Have you ever been convicted of a serious traffic violation, such as careless or reckless driving?*
Yes
No
Have you ever been convicted of a criminal offence for which no pardon has been granted?*
Yes
No
If Yes: Date; Location; Charge; Penalty;
Are you wanted or under indictment for a criminal offence?*
Yes
No
Have you within the two (2) years preceding the date of this proposal.*
Yes
No
Undergone an alcohol test in which concentration of 0.04 or greater was indicated?*
Yes
No
Undergone a controlled substance test in which positive result has been verified?*
Yes
No
Refused to undergo either an alcohol test or drug test or has a drug test verified?*
Yes
No
Had any other violations of Federal Motor Carrier Safety Administration drug or alcohol testing regulations?*
Yes
No
Successfully completed retum-on-duty requirements following violation of a D.O.T drug or alcohol regulation?*
Yes
No
Signature (Full Name):*

Date of application:*
MM slash DD slash YYYY

Did you have accidents for the past 3 years?*
Yes
No
If no, proceed with the next pages.
FATALITIES*

NATURE OF ACCIDENT (HEAD-ON, REAR-END, UPSET, ETC.)
HAZARDOUS MATERIAL SPILL*

TRAFFIC CONVICTIONS AND FORFEITURES FOR THE PAST 3 YEARS (OTHER THAN PARKING VIOLATIONS) IF NONE, LEAVE EMPTY
Location:*

Date*
MM slash DD slash YYYY

Charge:*
MM slash DD slash YYYY

PENALTY:*

EXPERIENCE AND QUALIFICATIONS – DRIVER List all driver licenses or permits held in the past 3 years
LICENSE NO.*

TYPE*

EXPIRATION DATE*

State*
State/Region ZIP Code

Additional (Optional):
LICENSE NO.

TYPE

EXPIRATION DATE

State
State/Region ZIP Code

A) Have you ever been denied a license, permit, or privilege to operate a motor vehicle?*
Yes
No
B) Has any license, permit, or privilege ever been suspended or revoked?*
Yes
No
IF THE ANSWER TO EITHER A OR B IS YES, GIVE DETAILS

STRAIGHT TRUCK*
Yes
No
(VAN,TANK,FLAT,DUMP,REFER)
Dates from/to:

DATES FROM (M/Y) TO (M/Y):
APPROX. NO. OF MILES (TOTAL)

TRACTOR AND SEMI-TRAILER*
Yes
No
(VAN,TANK,FLAT,DUMP,REFER)
Dates from/to:

DATES FROM (M/Y) TO (M/Y):
APPROX. NO. OF MILES (TOTAL)

TRACTOR – TWO TRAILERS*
Yes
No
(VAN,TANK,FLAT,DUMP,REFER)
Dates from/to:

DATES FROM (M/Y) TO (M/Y):
APPROX. NO. OF MILES (TOTAL)

TRACTOR – THREE TRAILERS*
Yes
No
(VAN,TANK,FLAT,DUMP,REFER)
Dates from/to:

DATES FROM (M/Y) TO (M/Y):
APPROX. NO. OF MILES (TOTAL)

MOTORCOACH – SCHOOL BUS
Yes
No
(VAN,TANK,FLAT,DUMP,REFER)
Dates from/to:

DATES FROM (M/Y) TO (M/Y):
APPROX. NO. OF MILES (TOTAL)

MORE THAN:*
8 passengers
16 passengers

Other:
LIST STATES OPERATED IN FOR THE LAST FIVE YEARS:*
SHOW SPECIAL COURSES OR TRAINING THAT WILL HELP YOU AS A DRIVER: *

WHICH SAFE DRIVING AWARDS DO YOU HOLD AND FROM WHOM?

EXPERIENCE AND QUALIFICATIONS – OTHER
SHOW ANY TRUCKING, TRANSPORTATION OR OTHER EXPERIENCE THAT MAY HELP IN YOUR WORK FOR THIS COMPANY*

LIST COURSES AND TRAINING OTHER THAN SHOWN ELSEWHERE IN THIS APPLICATION*

LIST SPECIAL EQUIPMENT OR TECHNICAL MATERIALS YOU CAN WORK WITH (OTHER THAN THOSE ALREADY SHOWN*

EDUCATION
HIGHEST GRADE COMPLETED
1
2
3
4
5
6
7
8
HIGH SCHOOL
1
2
3
4
COLLEGE
1
2
3
4
LAST SCHOOL ATTENDED
Name:*

Last School Attended.
City/State*
City State / Province / Region

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.
Full Name*
First Middle Last
Date*
MM slash DD slash YYYY

In accordance with the provisions of Sections 604 and 607 of the Fair Credit Reporting Act, Public Law 91-508, as amended by the Consumer Credit Reporting Act of 1996 (Title II, Subtitle D, Chapter 1, of Public Law 104-208), I hereby certify the following:

1. The consumer (contractor) has authorized in writing the procurement of this report;

2. The consumer (contractor) has been informed in a separate written disclosure that a consumer report may be obtained for contracting purposes;

3. The information requested below will be used for a “permissible purpose” (i.e., information for contracting purposes) and will be used for no other purpose;

4. The information being obtained will not be used in violation of any federal or state equal opportunity law or regulation; and

5. Before taking an adverse action based in whole or in part on the report the consumer (contractor) will receive a copy of the requested report and the summary of consumer rights as provided with the report by the consumer reporting agency

I also hereby certify that this report request and the above contractor’s release notice meet the definition of “permissible uses” of state motor vehicle records under the provisions of the Driver’s Privacy Protection Act of 1994 (Public Law 103-322, Title XXX, Section 300002(a))
Contractor's Full Name*
First Middle Last
Date*
MM slash DD slash YYYY

In accordance with Section 391.25, Federal Department of Transportation Regulations, please furnish the undersigned with the contractor’s driving record for the past year.
Name of contractor:*
First
Date of birth:*
MM slash DD slash YYYY

SSN:*
SSN Should have maximum of 9 numbers
Address*
Street Address City State / Province / Region ZIP / Postal Code Country

Former Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

REQUESTED BY:
VIP TRANS INC

Adress:
7667 W 95th Street Unit#305 Hickory Hills, IL
Zip:
60457

In accordance with the provisions of Sections 604 and 607 of the Fair Credit Reporting Act, Public Law 91-508, as 104-208), I hereby certify the following:

1. The consumer (contractor) has authorized in writing the procurement of this report;

2. The consumer (contractor) has been informed in a separate written disclosure that a consumer report may be obtained for contracting purposes;

3. The information requested below will be used for a “permissible purpose” (i.e., information for contracting purposes) and will be used for no other purpose;

4. The information being obtained will not be used in violation of any federal or state equal opportunity law or regulation; and

5. Before taking an adverse action based in whole or in part on the report the consumer (contractor) will receive a copy of the requested report and the summary of consumer rights as provided with report by the consumer agency.

I also hereby certify that this report request and the above contractor’s release notice meet the definition of “permissible uses” of state motor vehicle records under the provisions of the Driver’s Privacy Protection Act of 1994 (Public Law 103-322, Title XXX, Section 300002(a)).
Consent*
I read everything and I understand
Full Name of Requester:*
First Middle Last
Date*
MM slash DD slash YYYY

Company: VIP TRANS, INC – Qualification Proposal for Independent Contract Driver.

By signing this applicant waiver document the applicant is authorizing the procurement of a consumer report by this company as part of the pre-employment background investigation. If hired, this authorization shall remain on file and shall serve as an ongoing authorization to procure consumer reports at any time during my employment period. Additionally, by signing this document this company is disclosing to you that a consumer report, including an investigative consumer report containing information as to your character, general reputation, personal characteristics, public record information, previous employer reviews, education records, criminal history, personal references, driving records, credit, and mode of living may be obtained from Federal, State and other agencies, companies and other organizations for employment purposes as part of the pre-employment background investigation and at any time during your employment. If this company considers any information in the “consumer report” when making an employment related decision that directly and adversely affects you , you will be provided with a copy of the consumer report before the decision is finalized. You will also be provided a written summary of your rights under the Fair Credit Reporting Act.

I authorize without reservation any party or agency contacted by this company, employees, agents, and assigns to furnish the above-mentioned information. I hereby release and discharge this company and the CRA Consumer Reporting Agency (s) requesting, investigating and /or providing information and /or consumer reports and their employees, agents, successors and assigns, from any and all liability that may arise out of the investigative and/or consumer report of my background as set forth herein.

I certify that the facts contained in this application are true to the best of my knowledge and understand that if employed, falsified statements on this application shall be grounds for dismissal. Further, I understand and agree that I may be required to take and pass a drug test as a condition for hiring and/or continued employment. (Drug testing includes pre-employment, random, reasonable suspicion, post-accident, and follow up.) I agree to consent to take such test (s) at such time as designated by this company and to release this company, its agents, officers or employees from any claim arising in connection with the use of such tests.

I understand and agree that if hired, my employment is for no definite period and may regardless of the date of payment of my wages and/or salary, be terminated, with or without cause, at the option of either this company or myself at will.

PLEASE SIGN BELOW TO SIGNIFY RECEIPT OF THE FOREGOING DISCLOSURES.

Print Name*
First Last
SSN:*
SSN should have maximum of 9 numbers
Date
MM slash DD slash YYYY

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 VIP TRANS 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.

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.

Consent*
I understand

AUTHORIZATION

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

I authorize VIP TRANS 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 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

Consent*
I understand
Full Name*
First Last
Date:*
MM slash DD slash YYYY

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.

LAST UPDATED 12/22/2015

VIP TRANS INC.

Application form

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