Application – Other

All driver applicants to drive in interstate commerce must provide the following information on all employers during the preceding 3 years. Complete all data for EACH last employer COMPLETELY. 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. Sec. 391.21 (b) (10) (11).

A separate Safety Performance History Investigation form must be completed and submitted for each employer that you have worked for within the last 3 years link

1. I give full permission for Fortrans, Inc to obtain a Department of Motor Vehicle (DMV) report and understand the company may take appropriate action for any violations discovered.
2. I agree to report all citations issued for moving violations, accidents, and suspension/revocation of driver's license immediately to my supervisor.
3. I understand Fortrans, Inc may revoke my driving privileges at any time.
4. I understand it is Fortrans, Inc policy that I submit a drug and alcohol test following any accident with a company vehicle or personal vehicle during working hours.

I certify that I personally completed this form and that all of the information is true and correct. I authorize Fortrans, Inc. to conduct a thorough background investigation in accordance with state and federal law and authorize my previous employers to release any information requested by Fortrans, Inc. and hold them harmless of all liability from the release of said information. Also, in accordance with the provisions of 49 CFR Part 382.405 and 382.413, I hereby authorize and require my previous and/or current employers specifically listed by me on the Job Application form to release the results (including any refusal to test) of all drug and alcohol tests taken by me pursuant to the provisions of 49 CFR while in their employment to Fortrans, Inc. by whatever means is most expedient.

 

In connection with your application for employment with Fortrans, Inc., it may obtain one or more reports regarding your credit, driving, and/or criminal background history from a consumer reporting agency and/or other sources. If Fortrans, Inc. uses any information it obtains from a background report in a decision to not hire you or to make any other adverse employment decision regarding you, Fortrans, Inc. 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 on a background report, Fortrans, Inc. will notify you that the action has been taken and that the background report was the reason for the action. Fortrans, Inc. cannot obtain background reports from consumer reporting agencies or other sources regarding you unless you consent in writing. If you agree that Fortrans, Inc. may obtain such background reports, please read the following and sign below:

I authorize Fortrans, Inc. to contact any organization or individual that I have listed on my employment application or resume or mentioned in job interviews and obtain from them any relevant information about my job qualifications, including my experience, skills and abilities. 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, as well as any reference related information about me held or known by my former employers, supervisors, and co-workers. In addition, I consent to the release of any information about my education, experience, abilities or work-related characteristics or traits held or known by other organizations or individuals, including schools and educational institutions, professional or business associates, and friends and acquaintances that Fortrans, Inc. might contact in the course of conducting a reference check or background investigation of my suitability for employment.

I understand and acknowledge that this release of information can involve my qualifications, performance, credentials, or other characteristics or factors affecting my suitability for employment with Fortrans, Inc. Specifically, I am authorizing the release of any information about my performance, experience, capability, attitude, specific events, or other work-related characteristics that currently are in the possession of the requested organizations or their managers or representatives.

In exchange for Fortrans, Inc. consideration of my employment application, I agree not to file or pursue any complaints, claims or legal actions of any kind against any organization or individual that provides work-related information about me to Fortrans, Inc or its agents in accordance with the terms and intent of this release. I also agree not to file or pursue any complaints, claims or legal actions against Fortrans, Inc. or any of its employees, representatives, or agents arising out of their efforts to obtain work-related information about me. I understand employment or authorization to drive with Fortrans, Inc. is on an “at-will” basis that allows me to quit or be terminated at any time with or without cause.

In connection with your application for employment with FORTRANS, 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.

AUTHORIZATION

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

I authorize FORTRANS, 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.