Application for Employment

We anticipate that completing this employment application may take at least 15 minutes and must be completed in one session. We recommend you have your driver’s license and previous employer information for the past three (3) years available. Thank you.

In compliance with Federal and State equal employment opportunity laws, qualifed applicants are considered for all positions without regard to race, color, religion, sex national origin, age, marital status, veteran status, non-job related disability, or any other protected group status.

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Name*
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Enter addresses to cover the past 3 years.*
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Address #2
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Address #3
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Do you have the legal right to work in the US?
Are you over 18?
Have you worked for this company before?
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Are you employed now?
(Answer only if a job requirement)

EMPLOYMENT HISTORY
Provide employment information for the past 3 years.

Address
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Address
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Address
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Address
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MILITARY STATUS

Have you ever served in the US Armed Forces?

EDUCATION

Highest Grade Completed:
High School:
College:

EXPERIENCE AND QUALIFICATIONS - DRIVER

DRIVER LICENSES:

Have you ever been denied a license, permit or privilege to operate a motor vehicle?
Has any license, permit or priviledge ever been suspended or revoked?

DRIVING EXPERIENCE:

ACCIDENT RECORD FOR PAST 3 YEARS OR MORE:

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TRAFFIC CONVICTIONS AND FORFEITURES FOR THE PAST 3 YEARS
Other than parking violations.

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EXPERIENCE AND QUALIFICATIONS - PLATFORM

EXPERIENCE AND QUALIFICATIONS - MAINTENANCE

Equipment you can operate

EXPERIENCE AND QUALIFICATIONS - CLERICAL

Indicate training in clerical work:

EXPERIENCE AND QUALIFICATIONS - OTHER

TO BE READ AND SIGNED BY APPLICANT

This certifies that this application was completed by me, and that all entries on it and in it are true and complete to the best of my knowledge.

I authorize you to make such investigations and inquires of my personal, employment, financial or medical history and other related matters as maybe 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 inquires 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.

Example Format: 05101975
(Please sign with your electronic signature, which consists of the first 2 letters of your first name, your full last name, and the last 4 digits of your social security number). Example, Joe Smith would sign as JoSmith6789.

USIS DOT D/A Disclosure and Authorization

PART I - DISCLOSURE AND AUTHORIZATION 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 USIS for the purpose of USIS transmitting such records to the USIS 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 results, occurringduring the previous three (3) years; (i) alcohol tests with a result of 0.04 or higher; (ii) verified positive drug tests; (iii) refusals to be tested (including adulterated and/or substituted tests); (iv) other violations of DOT drug and alcohol testing regulations (i.e., violations of 49 CFR 382 Subpart B); (v) information obtained from previous employers of a drug and alcohol rule violation; and (vi) any documentation of completion of the return-to-duty process following a rule violation.

If any company listed below furnishes USIS with information concerning items (i) through (vi) above, I also authorize such company to furnish the following information to USIS, if applicable: (i) dates of my negative drug and/or alcohol tests and/or tests with results below 0.04 during the previous three (3) years; and (ii) the name and phone number of any substance abuse professional who evaluated me during the previous three (3) years.

List all DOT-regulated employers you have applied with and/or worked for in a safety-sensitive function during the previous three (3) years.

Example Format: 8005551212
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By signing below, I certify that: (i) all information provided herein is complete and accurate; (ii) I have read and fully understand this Part I 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,promotion,retention or other lawful purpose;(v) I understand I may reviewthis document with legal counsel prior to signing; and (vi) facsimile or photographic copies of this authorization are as valid as an original.

Applicant Name*
(Please sign with your electronic signature, which consists of the first 2 letters of your first name, your full last name, and the last 4 digits of your social security number). Example, Joe Smith would sign as JoSmith6789.
Example Format: 05101975

PART II - CONSUMER REPORT AND INVESTIGATIVE CONSUMER REPORT DISCLOSURE

(FOR EMPLOYMENT PURPOSES)


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

Upon providing proper identification and complying with any applicable legal requirements, you have the right to request the nature and substance of all Information in USIS’s files pertaining to you at the time of your request, including but not limited to:(i) whether any Reports have been provided by USIS to other parties;(ii) identification of any Suppliers utilized by USIS in compiling such Reports; and (iii) identification of any recipients of Reports furnished by USIS within the two (2) year period preceding your request.USIS may be contacted by mail at P.O. Box 33181, Tulsa, Oklahoma, 74153, or by phone at (800) 381-0645.


California
Check this box if you are applying for employment in California and/or you are a California resident and, in either case, you wish to receive a copy of your credit report or investigative consumer report if one is obtained or assembled by USIS. Pursuant to the California Civil Code, you may view the file maintained on you by USIS during normal business hours. You may also obtain a copy of this file by submitting proper identification and paying applicable costs for such file, if required by law, by contacting USIS in person or by mail. USIS is required to have personnel available to explain your file to you and must explain to you any coded information appearing in your file. If you appear in person, a person of your choice may accompany you, provided that this person furnishes proper identification.
Oklahoma
Check this box if you are applying for employment in Oklahoma and/or you are an Oklahoma resident and, in either case, you wish to receive a copy of your consumer report if one is obtained or assembled by USIS.
Minnesota
Check this box if you are applying for employment in Minnesota and/or you are a Minnesota resident and, in either case, you wish to receive a copy of your consumer report if one is obtained or assembled by USIS.


PART II - AUTHORIZATION FOR RELEASE OF INFORMATION (FOR EMPLOYMENT PURPOSES)

I hereby authorize USIS to receive Information and disclose such Information to its customers for the purpose of making a determination as to my eligibility for employment, promotion, retention or other lawful purpose, If hired or contracted, I authorize USIS and the USIS customer named above (“Customer”) to retain this document on file to act as ongoing authorization for the procurement and possession of Reports at any time during my employment or contract period.I fully release USIS and Suppliers from all claims of damages related to the investigation of my background and provision of Information as set forth in this disclosure and authorization.I agree that Information in USIS’s possession an my employment history with Customer if I am hired, may be supplied by USIS to other USIS customers for legally permissible purposes; provided, such Information will not include the Drug and Alcohol information set forth in Part I above, unless I have given a separate specific consent for USIS to share such Information.

By signing below, I certify that: (i) all information provided herein is complete and accurate; (ii) I have read and fully understand this Part II 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, promotion, retention or other lawful purpose; (v) I understand I may review this document with legal counsel prior to signing;(vi) I authorize USIS and any person or entity contacted byUSISto furnish the above-mentioned Information; and (vii) facsimile or photographic copies of this authorization are as valid as an original.


NOTE - THIS AUTHORIZATION DOES NOT APPLY TO DRUG & ALCOHOL INFO. ADDRESSED IN PART I.

Applicant Name*
(Please sign with your electronic signature, which consists of the first 2 letters of your first name, your full last name, and the last 4 digits of your social security number). Example, Joe Smith would sign as JoSmith6789.
Example Format: 05101975

REQUEST FOR INFORMATION FROM PREVIOUS EMPLOYER

I hereby authorize you to release the following information to FEPCO for purposes of investigation as required by Section 391.23 of the Federal Motor Carrier Safety Regulations. You are released from any and all liability which may result from furnishing such information.

Applicant Name*
(Please sign with your electronic signature, which consists of the first 2 letters of your first name, your full last name, and the last 4 digits of your social security number). Example, Joe Smith would sign as JoSmith6789.
Example Format: 05101975

PREVIOUS EMPLOYER ALCOHOL & DRUG TEST INFORMATION

I hereby authorize the following employer(s) to release and forward information concerning my Alcohol and Controlled Substances Testing records within the previous 3 years from date of this application.

Applicant Name*
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Address
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Please complete information for additional previous employers, if necessary, to cover the previous 3 years from the date of this employment application.

Address
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Address
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This information is being requested In compliance with sections 40.25(g) and 391.23(h).

(Please sign with your electronic signature, which consists of the first 2 letters of your first name, your full last name, and the last 4 digits of your social security number). Example, Joe Smith would sign as JoSmith6789.
Example Format: 05101975

DISCLOSURE AND CONSENT FOR BACKGROUND VERIFICATION REPORT

DISCLOSURES:

This form, which you should read carefully, has been provided to you because FEPCO may request Consumer Reports and/or Investigative Consumer Reports from a consumer reporting agency. The Company will use any such report(s) for the purpose of evaluating you for your staffing assignment.

Consumer Reports or Investigative Consumer Reports will be obtained from a consumer reporting agency, such as, for example, HireRight. Inc., ('HireRight") located at 5151 California Avenue, Irvine, CA 92617. They can be contacted at 866-521-6995. Any such reports may contain information bearing on your character, general reputation, personal characteristics, mode of living and credit standing. The types of information that may be obtained include, but are not limited to: credit reports, social security number, criminal records checks, public court records checks, including civil, driving records, educational records, verification of employment positions he1d, workers compensation records, personal and professional references, licensing, certification, etc. The information contained in these reports may be obtained by HireRight from private or public record sources including sources identified by you in your job application or through interviews or correspondence with your past or present coworkers, neighbors, friends, associates, current or former employers, educational institutions or other acquaintances.

You are being given a copy of the "Summary of Your Rights Under the Fair Credit Reporting Act" prepared pursuant to 15 U.S.C. section 1681(g)(c). You have the right to request additional disclosures of the nature and scope of the investigation and a statement of your rights by contacting HireRight.

Information about HireRight's privacy practices is available at: www.hireright.com/Privacy-Policy.aspx

CONSENT:

You understand that any information about you which is obtained by FEPCO during this process may be retained by FEPCO for purposes of considering you for employment of a contractor role, staffing assignments, as well as for more general management and internal research purposes.

Your signature below affirms that you have careful1y read and understand this Disclosure and Consent form and consent to the release of consumer and/or investigative consumer reports, as defined above, to the Company, You further understand that any and all information you provided or otherwise disclosed to the Company by you before, during or after your employment (or contract assignment), if any, may be utilized for the purpose of obtaining the consumer reports or investigative consumer reports by the Company.

You understand that your consent will apply throughout your employment (or the duration of my contract assignment), to the extent permitted by law, unless you revoke or cancel your consent by sending a letter or statement to the Company at any time.

This Disclosure and Consent form, in original, faxed, photocopied or electronic form, will be valid for any reports that may be requested by the Company.

VOLUNTARY AGREEMENT AND RELEASE OF LIABILITY FOR BACKGROUND INVESTIGATION

My signature below constitutes my voluntary agreement to undergo a background investigation program ("Program") in conjunction with my staffing or contract assignment. The program will be conducted by FEPCO’s agent, HireRight ("Agency"), who will procure a background check for security clearance purposes for my staffing or contract assignment. I understand that my refusal to sign this agreement, failure to sign the Agency's Background Investigation Authorization/Disclosure form, or denial of the security clearance will result in my inability to be assigned.

I further understand that Agency will disclose the results of its background investigation to FEPCO and. if assignment is for a client engagement, the client bas the right to review the results of the background check as part of an audit to confirm FEPCO’s compliance with the client's security requirements, if applicable. I understand that the results of my background investigation will contain sensitive personal data such as details of my criminal, employment, education and motor vehicle records and I consent to FEPCO’s processing of such sensitive personal data and, if assigned to a client engagement, the client's review of such sensitive personal data.

APPLIES TO FEPCO PERSONNEL ONLY


I understand that this release does not alter the nature of my employment relationship with FEPCO, which remains "at-will, meaning it is terminable at any time, for any reason or no reason, by either FEPCO or me, (including FEPCO's right in its discretion to terminate my employment based upon the background investigation results or its inability to reassign me to another available position) and that FEPCO may change the terms of employment, including but not limited to work hours, work schedules and location of work, at any time at its discretion, with or without cause or notice. I agree to release and hold harmless FEPCO, its partners, employees and agents from any liability whatsoever on account of, or arising from, the request for me to participate in FEPCO’s background check program or the client's background check program or the disclosure of the results of the investigation,

APPLIES TO NON-PERSONNEL ONLY (Contractors, Self Employed, Independent Contractors, etc.)

I understand that this release does not alter the nature of my employment relationship with my employer or my contracting relationship with FEPCO. I agree to release and hold harmless FEPCO, its partners, employees and agents from any liability whatsoever on account of, or arising from, the request for me to participate in the program or the disclosure of the results of the investigation in connection with the program.

This Disclosure, Consent form and Release of Liability, in original, faxed, photocopied or electronic form, will be valid for any reports that may be requested by the Company.

ADDITIONAL STATE LAW NOTICES

If you are a California, Maine, New York or Washington applicant, please also note:

CALIFORNIA: Under section 1786.22 of the California Civil Code, you may view the file maintained on you by HircRight during normal business hours. You may also obtain a copy of this file, upon submitting proper identification and paying the costs of duplication services, by appearing at HireRight's offices in person, during normal business hours and on reasonable notice, or by mail. You may also receive a summary of the file by telephone, upon submitting proper identification. HireRight has trained personnel available to explain your file to you, including any coded information. If you appear in person, you may be accompanied by one other person, provided that person furnishes proper identification.

NEW YORK: You have the right, upon request, to be informed of whether or not a consumer report was requested. If a consumer report is requested, you will be provided with the name and address of the consumer reporting agency furnishing the report. You may inspect and receive a copy of the report by contacting that agency.

MAINE: You have the right, upon request, to be informed of whether an investigative consumer report was requested, and if one was requested, the name and address of the consumer reporting agency furnishing the report. You may request and receive from the Company, within five business days of our receipt of your request, the name, address and telephone number of the nearest unit designated to handle inquiries for the consumer reporting agency issuing an investigative consumer report concerning you. You also have the right, under Maine law, to request and promptly receive from all such agencies copies of any such reports.

WASHINGTON STATE: If we request an investigative consumer report, you have the right, upon written request made within a reasonable period of time after your receipt of this disclosure, to receive from us a complete and accurate disclosure of the nature and scope of the investigation we requested, You also have the right to request from the consumer reporting agency a written summary of your rights and remedies under the Washington Fair Credit Reporting Act.

California, Minnesota or Oklahoma applicants only: You will be provided with a free copy of any consumer reports or investigative Consumer reports obtained on you if you check the box below.

I wish to receive a free copy of the report.*
Applicant Name*
(Please sign with your electronic signature, which consists of the first 2 letters of your first name, your full last name, and the last 4 digits of your social security number). Example, Joe Smith would sign as JoSmith6789.
Example Format: 05101975

GCIC CONSENT FORM

I hereby authorize BALDWIN POLICE DEPARTMENT to receive any Georgia criminal history record information pertaining to me, which may be in the files of any state or local criminal justice agency in Georgia.

Applicant Name*
Address*
Example Format: 05101975
Sex
(Please sign with your electronic signature, which consists of the first 2 letters of your first name, your full last name, and the last 4 digits of your social security number). Example, Joe Smith would sign as JoSmith6789.
Example Format: 05101975

Special employment provisions

(check if applicable):

This authorization is valid for 180 days from the date of signature.

IMPORTANT NOTICE REGARDING BACKGROUND REPORTS FROM THE PSP Online Service

                                                                                              IMPORTANT DISCLOSURE  REGARDING BACKGROUND REPORTS FROM THE PSP Online Service


In connection with your application for employment with     FEPCO      (“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          FEPCO      (“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.
 
Date: __________________________  _______________________________________
Signature
 
___________________________________________
Name (Please Print)
 
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

I hereby give authorization by signing the Electronic Authorization Application for     FEPCO   



Example Format: 05101975
Applicant Name*
(Please sign with your electronic signature, which consists of the first 2 letters of your first name, your full last name, and the last 4 digits of your social security number). Example, Joe Smith would sign as JoSmith6789.
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