I have carefully read and understand this Disclosure and Authorization form and the attached summary of rights under the Fair Credit Reporting Act. By my signature below, I consent to preparation of background reports by a consumer reporting agency such as Pre-Employment Screening Program (“PSP”), HireRight, Inc. (“HireRight”), and to the release of such background reports to Northern Steel Transport Co. and its designated representatives and agents, for the purpose of assisting Northern Steel Transport Co. in making a determination as to my eligibility for employment (including independent contractor assignments, as applicable), promotion, retention or for other lawful employment purposes. I understand that if Northern Steel Transport Co. qualifies me or contracts for my driving services, my consent will apply, and Northern Steel Transport Co. may, as allowed by law, obtain additional background reports pertaining to me, without asking for my authorization again, throughout my employment or contract period from HireRight and/or other reporting agencies.
I understand that information contained in my employment or contractor application, or otherwise disclosed by me before or during my employment or contract assignment, if any, may be used for the purpose of obtaining and evaluating background reports on me. I also understand that nothing herein shall be construed as an offer of employment or contract for services.
I hereby authorize all of the following, without limitation, to disclose information about me to the consumer reporting agency and its agents: law enforcement and all other federal, state and local agencies, learning institutions (including public and private schools, colleges and universities), testing agencies, information service bureaus, credit bureaus, record/data repositories, courts (federal, state and local), motor vehicle records agencies, my past or present employers, the military, and all other individuals and sources with any information about or concerning me. The information that can be disclosed to the consumer reporting agency and its agents includes, but is not limited to, information concerning my employment and earnings history, education, credit history, motor vehicle history, criminal history, military service, professional credentials and licenses.
By my signature below, I also certify the information I provided on and in connection with this form is true, accurate and complete. I agree that this form in original, faxed, photocopied or electronic (including electronically signed) form, will be valid for any background reports that may be requested by or on behalf of the Company.
California, Minnesota or Oklahoma applicants only: Please check this box if you would like to receive (whenever you have such right under the applicable state law) a copy of your background report if one is obtained on you by the Company.
List your addresses of residency for the past 3 years: CURRENT PHYSICAL ADDRESS:
PREVIOUS ADDRESS(S):
DO YOU HAVE THE LEGAL RIGHT TO WORK IN THE US?
HAVE YOU EVER BEEN UNDER CONTRACT OR APPLIED WITH THIS COMPANY BEFORE?
ARE YOU PRESENTLY UNDER CONTRACT/EMPLOYED WITH ANOTHER CARRIER?
IS THERE ANY REASON, PHYSICAL OR ANY OTHER, THAT YOU MIGHT BE UNABLE TO PERFORM ANY JOB DUTIES OF AN OVER THE ROAD DRIVER?
ARE YOU CAPABLE OF HEAVY MANUAL WORK?
EVER INJURED ON THE JOB?
DURING THE PAST THREE YEARS, WERE YOU EVER DENIED A POSITION BECAUSE YOU TESTED POSITIVE, OR REFUSED TO TEST, ON A DOT PRE-EMPLOYMENT DRUG OR ALCOHOL TEST?
DID YOU HAVE FLAT BED EXPERIENCE?
DID YOU HAVE MULTI-AXLE EXPERIENCE?
DID YOU HAVE STEEL COIL EXPERIENCE?
DID YOU HAVE DRY BOX EXPERIENCE?
WERE YOU SUBJECT TO THE FMCSR’s WHILE AT THIS COMPANY?
WAS YOUR JOB DESIGNATED AS A SAFETY-SENSITIVE FUNCTION IN ANY DOT-REGULATED MODE SUBJECT TO THE DRUG & ALCOHOL TESTING REQUIRMENTS OF 49 CFR PART 40?
HAVE YOU EVER BEEN DENIED A LICENSE, PERMIT OR PRIVILEGE TO OPERATE A MOTOR VEHICLE?
HAS ANY LICENSE, PERMIT OR PRIVILEGE EVER BEEN SUSPENDED OR REVOKED?
The information that has been provided herein is in accordance with 391.21(b)(10) may be used for the purpose of investigation and inquiry as required in 391.23.
I authorize Northern Steel Transport Co. to make such investigations and inquiries of my personal, employment and earnings history, education, credit history, motor vehicle history, criminal history, military service, professional credentials and licenses and other related matters as may be necessary in arriving at an employment decision.
I hereby authorize all of the following, without limitation, to disclose information about me to the consumer reporting agency and its agents: law enforcement and all other federal, state and local agencies, learning institutions (including public and private schools, colleges and universities), testing agencies, information service bureaus, credit bureaus, record/data repositories, courts (federal, state and local), motor vehicle records agencies, my past or present employers, the military, and all other individuals and sources with any information about or concerning me and I hereby release them from all liability in responding to inquiries and releasing information in connection with my application. I also understand that any expenses that may rise out of these inquiries maybe done at my expense.
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 Northern Steel Transport Co.
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:
This certifies that this survey form was completed by me, and that all entries on it and information in it are true & complete to the best of my knowledge.
6041 BENORE RD., P.O. BOX 6996TOLEDO, OHIO 43612(419) 729-3867 FAX (419) 729-1346
I, hereby authorize all named previous employers to release the following information to Northern Steel Transport Co for the purposes of investigation as required by 49 CFR of the Federal Motor Carrier Safety Regulations on my job performance, ability, and fitness. I also authorize all named previous employers to release information to Northern Steel Transport Co for the purposes of investigation and inquiring into my previous three (3) years of alcohol & controlled substance testing as required by 49 CFR of the Federal Motor Carrier Safety Regulations while I was performing a safety sensitive function. I have already been expressly notified of my rights under Section 391.23. I hereby release this company from any and all liability which may result from furnishing such information.
In connection with your application for employment with Northern Steel Transport Co. (“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.
If you agree that the Prospective Employer may obtain such background reports, please read the following and sign below:
I authorize Northern Steel Transport Co. (“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.
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 2/11/2016
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