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 also understand that I have the right under 49 CFR 391.23(i)(1) to:
• It is agreed and understood that the employer or its agents may investigate the applicant’s background to ascertain any and all information of concern to applicant’s 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 furnishing such information.
• In accordance with the provision so Section 604(b)(2)(a) of the Fair Credit Reporting Act Public Law 9f-508, as amended by the Consumer Credit Reporting Act of 1996 (Title II, Subtitle D, Chapter 1, of Public Law 104-208), you are being informed that reports verifying your previous employment, previous drug and alcohol test results, and your driving record may be obtained on you for employment purposes. These reports are required by Sections 382.413, and 391.25 of the Federal Motor Carrier Safety Regulations.
• The applicant agrees to furnish such additional information and complete such examinations as necessary to complete applicant’s employment file.
• It is agreed and understood that this application for employment in no way obligates the employer to employ the applicant.
• It is agreed and understood that if hired, the applicant may be on a probationary period during which time applicant may be discharged without recourse. Further, any false statement herein submitted will be deemed sufficient reason for rejection or termination of the applicant’s employment, irrespective of time lapsed before discovery.
• In connection with my application for employment with you, I understand that an investigative consumer report is being requested from Hire Right Services that will include information as to my character, work habits, performance, and experience, along with reasons for termination of past employment obtained from previous employers. Further, I understand that you will be requesting information concerning my driving record and/or information from various state agencies which maintain records concerning traffic offenses, accidents, etc., as well as information from Hire Right Services concerning (1) previous driving record requests made by others from such stage agencies and (2) claims involving me in the files of insurance companies. I have a right to make a written request within a reasonable period of time to receive additional detailed information about the nature and scope of this investigation. I hereby consent to your obtaining the above described information form Hire Right Services, and agree that such information which Hire Right Services has or obtains, and my employment history with you, if I am hired, will be supplied by Hire Right Services to other companies which subscribe to Hire Right Services.
• IF HIRED BY YOU, I FURTHER CONSENT TO YOUR FURNISHING TO HIRE RIGHT SERVICES INFORMATION CONCERNING MY CHARACTER, WORK HABITS, PERFORMANCE DRIVING RECORD AND EXPERIENCE, AS WELL AS ANY REASONS FOR TERMINATION OF MY EMPLOYMENT, AND FURTHER CONSENT TO HIRE RIGHT SERVICES FURNISHING SUCH INFORMATION IN THE FUTURE TO OTHER COMPANIES WHICH SUBSCRIBE TO HIRE RIGHT SERVICES FROM WHICH I MAY BE SEEKING EMPLOYMENT, AND TO INSURANCE COMPANIES OR THEIR AGENTS IN CONNECTION WITH ISSUANCE OR MAINTENANCE OF INSURANCE COVERAGE.
• The applicant agrees to conform to the rules and regulations of the Company, and understands that employment and compensation can be terminated with or without cause, at any time, at the option or either the Company or the individual.
• The applicant further understands that no personnel recruiter or interviewer or other representative of the Company other than the President, has any authority to enter into any agreement for employment for any specified period of time.
• If requested to do so, I agree to submit to physical and psychological testing prior to employment, or at any time during my employment, including but not limited to a polygraph and/or urine analysis to test for drugs or alcohol. It is agreed and understood that the answers to the foregoing questions are true and correct, and that any misrepresentations of information given above shall be considered an act of dishonesty. Further, this certifies that this application was completed by me, and that all entries on it and information in it are true and complete to the best of my knowledge.
Drivers must have 12 months of verified experience in the prior 3 years to be considered. It does not need to be consecutive, but it must be verified by previous employers or carriers that the driver hauled for. A current DOT medical card with at least 6 months remaining on it and the long form are also required to be considered for employment.
Motor Vehicle Records (MVR's)
Minimum 23 years of age.
Must have the correct license class and endorsements for the vehicle that they wilt be driving.
No more than 3 Jobs in the prior 3 years.
1 point violations
Improper stop on highway
Failure to yield
Improper backing or turning
2 point violations
Speeding 1-6 mph over limit
Traffic control device
Unsafe operation of a motor vehicle
3 point violations
Speeding 7-14 mph over limit
Any ticket in a school zone (plus the ticket itself)
1 at fault accident
4 point violations
A - Major violations (5 years)
DUI/DWI, drug or alcohol possession/conviction
False report to a police department
Fraudulent use of a driver license
Hit and run
Leaving the scene
Homicide with a motor vehicle
Manslaughter with a motor vehicle
Passing a school bus
Participating in racing
Eluding a police officer
Railroad crossing violation
B — Major violations (3 years)
Failure to report an accident
Failure to stop, aid or identify
Wrong way on a highway
Following too close
At fault accident with a fatality
Driving without or proper class CDL
Driving with a suspended/revoked license
2 or more at fault accidents
Allowing a non-licensed operator
Speeding over 15 mph above limit
Improper or erratic lane change
Texting or improper use of a handheld device
3 or more preventable accidents
Serious preventable accident: at fault rear end collision, rollover, jackknife, head on collision, etc.
3 or more moving violations
Violations/accidents in commercial or personal vehicles count.
All accidents on MVR’s of loss/runs will be considered at fault unless otherwise supported with a police report.
Terminal Transport and its insurance company reserve the right to determine an acceptable, insurable risk.
These rules are meant solely as tools to determine insurability and acceptability of risk.
In connection with your application for employment with Terminal Transport 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.
If you agree that the Prospective Employer may obtain such background reports, please read the following and sign below:
I authorize Terminal Transport 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.
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.
LAST UPDATED 12/22/2015
Please list each employer starting with most recent
* The Federal Motor Carrier Safety Regulations apply to anyone operating a motor vehicle on a highway in interstate commerce to transport passengers or property when the vehicle: 1) weighs or has a GVWR of 10,001 pounds or more, 2) is designed or used to transport 9 or more passengers, or 3) is of any size and is used to transport hazardous materials in a quantity requiring placarding.
** Any gaps in employment of more than 30 days must be explained.
*** A complete 10 year employment history is required by Federal DOT, whether it is driving related or not.
Phone: 651-414-6057 - Fax: 651-407-6300 - Email: firstname.lastname@example.org
Pursuant to §391.23 of FMCSR, please provide information concerning the following questions. Within the last 3 years has this driver ever: Please select Yes or No.
If answering yes to any of the above questions, please give the following SAP information further reference.
Regulations require all employment be verified for the last ten years. Other forms of employment verification required (choose one or more). Please send them to email@example.com
I certify that all entries are true and complete. I am submitting this form as an addendum to my application for verification purposes.
All applicants are required to provide a copy of their driver's license and their medical card. If you are unable to do it electronically with the form below, please send a copy of your license and medical card to:
Terminal Transport, Inc.
2982 Cleveland Ave. North
Roseville, MN 55113
Please provide a copy of your driver license
Please provide a copy of your medical card
2982 Cleveland Ave. North, Roseville, MN 55113 | P-800.432.4340, | F-651.407.6300