I understand that the information in this application will be used and that prior employers will be contacted for purposes of investigation as required by Section 391.23 of the Federal Motor Carrier Safety Regulations.
It is agreed and understood that the employer or his agents may investigate the applicants background to ascertain any and all information of concern to applicants record, whether same is of record or not, and applicant releases employers and persons named herein from all liability for any damages on account of his furnishing such information.
It is also agreed and understood that under the Fair Credit Reporting Act, Public Law 91-508; I have been told that this investigation may include an investigative Consumer Report, including information regarding my character, general reputation, personal characteristics, and mode of living. I agree to furnish such additional information and complete such examinations as may be required to complete my employment file.
(GA & KS) – I understand that, as a condition of employment, I will obtain from State Motor Vehicle Agency, within my probationary period, and without cost to the employer, a copy of my motor vehicle violations record.
(MA) – “An applicant for employment with a sealed record on file with the commissioner of probation may answer “no record” with respect to any injury herein relative to prior arrests, criminal court appearances or convictions. An applicant for employment with a sealed record on file with the commissioner of probation may answer “no record” with respect to any injury herein relative to prior arrests, criminal court appearances and adjudications in all cases of delinquency or as a child in need of services which do not result in a complaint transferred to the superior court for criminal prosecution. :
(MD) – “AN EMPLOYER MAY NOT REQUIRE OR DEMAND ANY APPLICANT FOR EMPLOYMEMT OR
PROSPECTIVE EMPLOYMENT OR ANY EMPLOYEE TO SUBMIT TO OR TAKE A POLYGRAPH, LIE DETECTOR OR SIMILAR TEST OR EXAMINATION AS A CONDITION OF EMPLOYMENT OR CONTINUED EMPLOYMENT, ANY EMPLOYER WHO VIOLATES THE PROVISION IS GUILTY OF A MISDEMEANOR AND SUBJECT TO A FINE NOT TO EXCEED $ 100.00
(PA) – I authorize my employer to obtain from the Registry of Motor Vehicles a copy of my Motor Vehicle Violations Records.
I HEREBY CERTIFY that my answers to the foregoing questions are true and complete and that I have not knowingly withheld any facts, circumstances or other information which would if disclosed, affect my application. I further understand that any false or misleading statement or omission of pertinent information will result in the rejections of my application or in dismissal if discovered subsequent to my employment. Inquiries may be made with my previous employers or others who may have knowledge of me or with consumer credit, investigative, or other private or governmental agencies. I authorize any such person or agency to give you any and all information concerning my previous employment, including but not limited to an assessment of my job performance, ability, and fitness, and/or any other information they have, personal or otherwise. I also hereby release all parties from any and all liability, claims, or damages that may directly or indirectly result from furnishing it. I understand and acknowledge that this release may be extended to information obtained from Internet sources including but not limited to social networking websites, which could have a bearing on my suitability for employment. Upon my reasonable and timely request, a description of the general scope and nature of any such inquiry will be provided to me.
I HEREBY AFFIRM that by submitting this application I agree to a medical evaluation and/or examination, including tests for the presence of illegal drugs or alcohol, prior to and during employment, within a time period prescribed by the company and as often as directed during employment. I HEREBY AUTHORIZE the medical examiner to disclose to the company any and all findings and conclusions arrived at in any examination performed either prior to employment or during employment. I may be required to provide proof of having a driving record acceptable to employer and/or employer’s insurance carrier, and, if employed, maintain a valid driver’s license and continue to provide proof of having an acceptable driving record. I UNDERSTAND that if I am employed the terms and condition of my employment will be governed by this application and the company’s terms of employment and Policy and
Procedures, as amended from time to time by the company.
FAIR CREDIT REPORTING ACT DISCLOSURE STATEMENT
In accordance with the provisions of Section 604(b)(2)(A) 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 I of Public Law 104-208), you are being informed that reports verifying your previous employment, previous drug & alcohol test results, and your driving record may be obtained on you for employment purposes. These reports are required by Sections 382.413, 391.23, and 391.25 of the Federal Motor Carrier Safety Regulations.
Request for Driver’s Safety Performance History Information from DOT Regulated Previous Employer(s)
As a Commercial Motor Vehicle (CMV) Driver, I understand that per, the Federal Motor Carrier Safety Regulations (FMCSRs) Part 391.21, the following information will be requested from all previous employers for which I operated a CMV, subject to the FMCSR Parts 390 and/or 40, 382, & 383, within the past three years, from the date shown below. I also acknowledge that this information will be used in determining my eligibility to be hired, that I have the right to review this information and rebut any errors in these statements from my prior employers, as described in the FMCSR Part 391.23.
I hereby authorize this company to release all records of employment, including assessments of my job performance, ability and fitness, including dates of any and all alcohol or drug tests. Those confirmed results and/or my refusal to submit to any alcohol or drug tests and any rehabilitation competition under direction of (SAP/MRO) to each and every company (or their authorized agents) which may request such information in connection with my application for employment with said company. I hereby release this company, and its employees, officers, directors, and agents from any and all liability of any type as a result of providing information to the above-mentioned person and/or company.
PRE-EMPLOYMENT SCREENING PROGRAM (PSP) AUTHORIZATION
REGARDING BACKGROUND REPORTS FROM THE PSP Online Service
1. In connection with your application for employment Gazelle Transportation, Inc, 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:
2. I authorize Gazelle Transportation, Inc 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.
3. 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.
4. 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.
VALIDEX AUTHORIZATION AND DISCLOSURE
I authorize Gazelle Transportation, Inc. and Validex Employment Screening (“Validex”) to conduct, prior to or after employment begins, a background investigation. I understand that an investigative consumer report may be requested, which may contain information pertaining to my character, general reputation, personal characteristics, and mode of living obtained through personal interviews.
I knowingly authorize and request any federal or state agency, local agency, college university, former employer, or other persons to provide information or records they may have concerning any military records, character, employment credit history, criminal history, workers compensation, motor vehicle history, drug test results, academic records, licenses and certifications, or any other information requested by Validex. I acknowledge that the reports may contain any of the above information.
I understand that Validex is a consumer reporting agency and that while reports are written in plain language. Validex will provide a written explanation of any questions I may have concerning my report.
I understand that any Consumer report or Investigative Consumer Report will be used only for permissible purposes under the Fair Credit Reporting Act. Those purposes are evaluation for employment, promotion, reassignment or retention as an employee. Also, I understand that upon a conditional offer of employment, the report may include medical inquiries and workers’ compensation history in compliance with the ADA.
I understand that I have the right to request from Validex, upon proper identification, the nature and scope of all information in its files on me at the time of my request, including sources of information, and the recipients of any reports on me which Validex has previously furnished within the two year period preceding my request. Validex may be contacted at 324 W. Ninth St, Cincinnati, OH 45202 or at (800) 362-3201.
I understand that Gazelle Transportation, Inc. and Validex cannot guarantee the accuracy of any information reported to it by third parties, and I release Gazelle Transportation, Inc. and Validex from liability for damages that arise from errors or omissions in my background investigation and consumer report.
Specific state requirements:
California: A file maintained by Validex, LLC, on you, shall be available for visual inspection, upon furnishing proper identification and payment of the costs of duplication, in person, by mail, or you may receive a summary of your file by telephone. Trained personnel shall be available during normal business hours, to explain any information furnished. A written explanation of any coded information will be provided. If you appear in person, you may be accompanied by one other person, provided that person has proper identification.
Maine: An investigative consumer report which may include information as to your character, general reputation, personal characteristics and mode of living, whichever is applicable may be made. You may request and receive from the person who intends to obtain such a report, within 5 business days of that person’s receipt of his request, the name, and address and telephone number of the nearest unit designated to handle inquiries of each consumer reporting agency issuing an investigative consumer report about you. You may request and promptly receive from all such consumer reporting agencies copies of any such investigative consumer report.
New York: An investigative consumer report may be requested on you. Upon written request you have the right to be informed whether an investigative consumer report was requested and the name and address of the consumer reporting agency to whom the request was made. You may inspect and receive a copy of such report by contacting such agency
Agree and Accept (*)