DRIVERS APPLICATION

Driver Job Application

Step 1 of 3

Disclosure and Release of Information
IMPORTANT DISCLOSURE REGARDING BACKGROUND REPORTS FROM THE PSP Online Service
In connection with your application for employment with Simon’s Trucking 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 I authorize Simon’s Trucking, 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.
Release Form*
- I have read the Release Form above and agree to the terms.
Print Name
Signature*

Employment History Authorization
391.23 Investigation, Inquiries and Employment History Authorization

I authorize Simon’s Trucking, Inc to investigate my previous experience and qualifications and hereby release any parties furnishing such information from any resulting liabilities for damage. I hereby give Simon’s Trucking, Inc written authorization to obtain the results of all DOT required drug and/or alcohol records and a Pre-Employment Screen program record. This release is in accordance with FMCSA Part 391.23, Investigation and Inquiries. I authorize release of the following information concerning DOT drug and alcohol testing violations including pre-employment tests during the past three years: Alcohol tests with a result of 0.04 or higher alcohol concentration, Verified positive drug tests, Refusals to be tested, Other violations of DOT agency drug and alcohol testing regulations, documentation (if any) of completion of the return-to-duty process following a rule violation, and information obtained from previous employers of a drug and alcohol rule violation. You have a right to make a written request within a reasonable period of time for the complete and accurate disclosure of additional information concerning the nature and scope of the investigation.

I authorize Simon’s Trucking, Inc to contact any organization or individual that I have listed, or not listed but have employed me, on my employment/contract application or resume and obtain from them relevant information about my job qualifications, including my experience, skills, and abilities. I understand that I am consenting to the release of education, experience, abilities, or work-related information about me held or known by my former employers, supervisors, co-workers, educational institutions, professional or business associates, and friends and acquaintances that Simon’s Trucking, Inc might contact in the course of conduction of a reference check or background investigation of my suitability for employment/contract.

I give permission to obtain all DOT required drug and/or alcohol test results, consumer information including employment and driving records as well as background reports from the PSP Online Service. I agree not to file or pursue any complaints against Simon’s Trucking, Inc and/or any employees, representatives, or agents arising out of their respective efforts to obtain work-related, driving history, or criminal background information about me.

I declare the foregoing information to be a truthful and complete statement of the facts with the understanding that if found false, it may prevent my being hired or may cause my dismissal if hired. I also understand that, if hired, I can voluntarily terminate my employment or be terminated at any time, with or without cause.

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. I have read and agree to the above release.
Release Form*
- I have read the Release Form above and agree to the terms.
Print Name*
Signature*
Date of Application
MM slash DD slash YYYY
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Driver Job Application

Step 1 of 3

Previous Employment

Disclosure and Release of Information

Employment History Authorization

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