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Driver Application for Employment

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Note to Applicant: Please advise us in advance if you need any type of special accommodation to complete this application or to take any pre-employment test.


*Qualified applicants are considered for all positions without regard to age, sex, race, color, religion, national origin, sexual orientation, disability, marital and/or veteran status.

Name
If you have NOT been at this address for more than 7 years, list previous address.
Have you ever had any drivers’ license denied, suspended, revoked or cancelled by any issuing State agency?
Employment History, last 10 years FMCSA 383-35. Account for gaps between employers: (of Owner/Operator, list Carrier leased to).

BACKGROUND CHECK AUTHORIZATION AND RELEASE FORM

Name

I hereby authorize the release to Super T Transport, Inc., any and all information regarding my prior employment, criminal, credit, driving, workers compensation and educational history as well as information regarding my general character and reputation. I release any providers of such information from any liability for providing the information. I understand the information may be reviewed initially and periodically by Super T Transport, Inc.

I release Super T Transport, Inc. and their agents and assigns, from any and all demands and/or liabilities that may originate from these investigations, or any demand or liability which may result from any drug testing procedure, or other medical screening procedures conducted by them or their agents, and any person, corporation, company, institute or their agents who may act upon the authority of this release.

I agree falsification may make me ineligible for employment or subject to immediate dismissal, if hired. I further acknowledge that Super T Transport, Inc. is relying on third party information and I therefore release Super T Transport, Inc., my prospective/actual employer, and their respective owners, agents and employees from any and all liability arising out of errors or omissions.

I hereby authorize that a photocopy or electronic facsimile of this document shall serve as an original.

Important Notice

Regarding Background reoprts From the PSP online service

1.  In connection with your application for employment with Super T Transportation, Inc. it 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 Super T 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.

CONSUMER REPORT/INVESTIGATIVE CONSUMER REPORT DISCLOSURE

In connection with your employment or application for employment (including independent contractor assignments, if applicable) and in accordance with pertinent laws, HireRight may obtain or assemble consumer reports and/or investigative consumer reports (collectively, “Reports”) related to information concerning your: previous employment (including employers, dates of employment, salary information, reasons for termination, etc.), academic history, verification of references and verification of other information supplied by you, professional credentials, drug/alcohol use in violation of law and/or company policy, driving record, accident history, workers’ compensation claims, credit history, creditworthiness, credit capacity, bankruptcy filings, criminal history records and information about your character, general reputation, personal characteristics and mode of living (collectively, “Information”). Information may be obtained from government agencies, educational institutions, HireRight clients, personal references, personal interviews and other Information sources (collectively, “Suppliers”).


Upon providing proper identification and subject to applicable legal requirements and restrictions, you have the right to request the nature and substance of all Information in HireRight’s files pertaining to you, as well as information including, but not limited to: (i) whether any Reports have been provided by HireRight to other parties; (ii) identification of any Suppliers utilized by HireRight in compiling such Reports; and (iii) identification of any recipients of Reports furnished by HireRight within certain statutorily-prescribed time periods preceding your request. HireRight may be contacted by mail at P.O. Box 33181, Tulsa, Oklahoma, 74153, or by phone at (800) 381-0645.

If you are a Maine, Massachusetts, New York or Washington State applicant, employee or contractor, please also refer to the additional state law notices attached herewith.

AUTHORIZATION FOR RELEASE OF INFORMATION

I hereby authorize HireRight to obtain Information and disclose Information to its customers (“Customers”), if applicable, for the purpose of making a determination as to my eligibility for employment (including independent contractor assignments), promotion, retention or other lawful purpose. If hired or contracted, I authorize HireRight and HireRight Customers, if applicable, to retain this document on file to act as ongoing authorization for the procurement and assembly of Reports at any time during my employment or contract period. As permitted by law, I fully release HireRight and Suppliers from all claims of damages related to the investigation of my background and provision of Information as set forth in this document. I agree that Information in HireRight’s possession and my employment history with Customers if I am hired or contracted may be supplied by HireRight to other HireRight Customers for legally permissible purposes.

By signing below, I certify that: (i) all information provided herein is complete and accurate; (ii) I have read and fully understand this disclosure and authorization for release; (iii) prior to signing I was given an opportunity to ask questions and to have those questions answered to my satisfaction; (iv) I execute this authorization voluntarily and with the knowledge that the Information obtained pursuant to this authorization could affect my eligibility for employment, independent contractor status, promotion, retention or other lawful purpose; (v) I understand I may review this document with legal counsel prior to signing; (vi) I authorize HireRight and any person or entity contacted by HireRight to furnish the above-mentioned Information; and (vii) facsimile or e-mail copies of this authorization are as valid as an original.

PART 1- DISCLOSURE AND AUTHRIZATION FOR RELEASE OF INFORMATION FOR EMPLOYMENT PURPOSES - 49 CFR PART 391.23,DOT DRUG AND ALCOHOL TESTING

In accordance with DOT Regulation 49 CFR Part 391.23, I hereby authorize release of my DOT-regulated drug and alcohol testing records by the DOT-regulated employer(s) listed below to HireRight for the purpose of HireRight transmitting such records to the HireRight customer listed above. I understand that information/documents released pursuant to this part I is limited to the following DOT-regulated testing items, including pre-employment testing result, occurring during the previous three (3) years: (i) alcohol tests with a result of 0.04 or higher;(ii)verified positive drug test(iii)refusals to be tested(including dual terated and/or s substituted tests)(iv) other violations of DOT drug and alcohol test regulation (i.e violations of 49 CFR 382 sub part B);(V)information obtain from previous employee of drug and alcohol rule violations and(vi) documentation of complement of the return-to-duty process following a rule violations.


if any company listed below furnished HireRight with information concern items(i)through(vi)above,I also authorize such company to furnish the following information to HireRight, if applicable (i) dates of my negative drug and/or alcohol tests and/or tests with result below 0.04 during the previous three(3)year and(ii) the name and phone number of any substance abuse profession who involve me during previous three (3)year.


Have you ever been employed by a department of transportation employer?

By signing below ,i certify that (ii) all information provide herein is complete and accurate (ii) i have read fully understand this part i discloser and authentication for release all as well as the attached FMCSA notification of Drive right and any applicable state low notification (iii) prior to signing i was graving an opportunity to ask question answer to have those question answer to my satisfaction(iv) i execute this authorization voluntary and with the knowledge that the information obtained pursuant to this authorization could affect my eligibility for employment, promotion, retention or other photographic copies of this authorization are as valid as an original.

Part 2-FMCSA Notification of Driver Rights

In compliance with 49 CFR Part 40 §391.23 you have certain rights regarding the safety performance history information that will be provided to prospective employers. I) You have the right to review information provided by previous employers. II) You have the right to have errors in the information corrected by the previous employer and for that previous employer to re-send the corrected information to prospective employers. III) You have the right to have a rebuttal statement attached to the alleged erroneous information, if the previous employer and the driver cannot agree on the accuracy of the information. (2) Drivers who have previous DOT regulated employment history in the preceding three years and wish to review previous employer-provided investigative information must submit a written request to prospective employers. This may be done at any time, including when applying, or as late as 30 days after being employed or being notified of denial of employment. Prospective employers must provide this information within five business days of receiving the written request. If prospective employers have not yet received the requested information from the previous employer, then the five day deadline will begin when the requested safety performance history information is received. If you have not arranged to pick up or receive the requested records within 30 days of prospective employers making them available, the prospective employers may consider you to have waived your request to review the record.

Signature

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