DRIVER EXPERIENCE AND QUALIFICATIONS (Please list all licenses held for previous 3 yrs) CURRENT License # State Type Endorsement Expiration
CURRENT License # State Type Endorsement Expiration
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? If yes to either, please explain: DRIVING EXPERIENCE – IF NONE, WRITE NONE TYPE OF EQUIPMENT Straight Truck Tractor Traier Tanker Van Reefer End Dump Pneumatics Flatbed Other List States operated in the last 5 years List any Safe Driving Awards you have received Understand that any misrespresentation made by me in filling out this application shall be considered just cause for cancellation of employment. Applicant Signature Date
REQUEST FOR CHECK OF I authorize you to release the following information for the purpose of investigation to the company as required by section 391.23 of the FMCSR. You are released from any and all liability which may result from furnishing such information. Drivers Signature Date To:
The above listed individual has made application with the company as an independent contractor driver. The applicant has indicated that the numbered operator's license or permit below has been issued by a state agency and that it is in good standing. Drivers Name Address Former Address Date of Birth SS# DL# State Requested By: Universal, Inc. Address: 36862 Commerce Cir Trinidad, Co 81082 Motor Carrier Official Title:
CERTIFICATION OF COMPLIANCE WITH DRIVER LICENSE REQUIREMENTS MOTOR CARRIER INSTRUCTIONS: The requirements in Part 383 apply to every driver who operates in intrastate, interstate, or foreign commerce and operates a vehicle weighing or rated at 26,001 pounds or more, can transport more than 15 people, or transports hazardous materials that require placarding.The requirements in Part 391 apply to every driver who operates in interstate commerce and operates a vehicle weighing or rated 10,001 pounds or more, can transport hazardous materials that require placarding. DRIVER REQUIREMENTS: Parts 383 and 391 of the Federal Motor Carrier Safety Regulations contain certain driver licensing requirements that you as a driver must comply with including the following: 1. POSSESS ONLY ONE LICENSE: You, as a commercial vehicle driver, may not possess more than one motor vehicle operator's license. 2. NOTIFICATION OF LICENSE SUSPENSION, REVOCATION OR CANCELLATION: Sections 391.15(b)(2) and 383.33 of the Federal Motor Carrier Safety Regulations require that you notify your employer the NEXT BUSINESS DAY of any revocation, suspension, cancellation, or disqualification of your driver's license or driving privilege. In addition, Section 383.31 requires that any time you are convicted of violating a state or local traffic law (other than parking); you must report it within 30 days to your employing motor carrier. The notification must be in writing. 3. CDL DOMICILE REQUIREMENT: Section 383.23(a)(2) requires that your commercial driver’s license be issued by your legal state of domicile, where you have your true, fixed, and permanent home or principal residence and to which you have the intention of returning whenever you are absent. If you establish a new domicile in another state, you must apply to transfer your DCL within 30 days.
The following license is the only one I possess: Driver's License Number: State: Expiration Date: DRIVER CERTIFICATION: I certify that I have read and understood the above requirements. Driver's Name (Printed): Driver's Signature: Date: Notes: I understand that the Employer or Insurer (“Company”) has my authorization to thoroughly investigate my background. I understand that the background report may include, but is not limited to, the following areas: Motor Vehicle Records, Drivers License Verification, FMCSA PSP Records, Drug Screening Records, Pre-Employment Verification, Sexual Offender Lists, County Court Records and Identity Verification. If applicable and in accordance with DOT Regulation 49 CFR Part 391.23 and 49 CFR Part 40, I hereby authorize release of my DOT Regulated Drug and Alcohol Testing Records by any previous employers to the requesting employer via MVRcheck.com or another consumer reporting agency. Furthermore, I provide consent to conduct a limited query of the FMCSA Clearinghouse to determine whether drug or alcohol violation information about me exists in the Clearinghouse. I further understand that if I refuse to provide consent for Company/MVRcheck to conduct a limited query of the Clearinghouse, Company must prohibit me from performing safety-sensitive functions, including driving a commercial motor vehicle. I hereby authorize MVRcheck.com an agent of the Company to make a thorough background investigation of all information given by me to the Company. This authorization shall remain on file by Company for the duration of my employment and will serve as ongoing authorization for Company and MVRcheck.com to procure my driving and background records at any time during my employment period. Reports are to be generated for employment, promotion, reassignment, retention as an employee or insurance underwriting. I understand that Company may take adverse action affecting my employment, based on information in my background report. Upon written request, MVRcheck.com will supply a copy of the completed background report along with a copy of an individual’s rights under the Fair Credit Reporting Act and I also understand that I have the right to dispute the accuracy of my driving record with MVRcheck.com. A copy of this form is as valid as the original. The following information is required for identification purposes when checking records. It is confidential and will not be used for any other purpose. Applicant's Name Applicant's Date of Birth: Applicant's SSN (Last 4#): Driver's License No: State Issued: Address (Current): City: State Zip Code Company Requesting Report: Company Location (State): California, Minnesota and Oklahoma Applicants: Please check the box if you would like to receive a copy of your consumer report if one is obtained by the Company. Notice to New York Applicants: Under Article 25 Section 380-c (b)(2) of the New York General Business Law, you have the right, upon written request, to be informed of whether or not an investigative consumer report was requested. California Minesota Oklahoma Applicant Signature: Date: THE BELOW DISCLOSURE AND AUTHORIZATION LANGUAGE IS FOR MANDATORY USE BY ALL ACCOUNT HOLDERS IMPORTANT DISCLOSURE REGARDING BACKGROUND REPORTS FROM THE PSP Online Service In connection with your application for employment with Universal, 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 Universal, 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. Date: Signature: Name Print: NOTICE: This form is made available on behalf of the U.S. Department of Transportation, Federal Motor Carrier Safety Administration (FMCSA). It is required by federal law to obtain an Applicant’s written or electronic consent prior to accessing the Applicant’s PSP report. Further, companies 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 Spam Bot Stop Type in the sum below: 6+3
