My Intermodal, LLC — 1000 Trident St., Hanahan, SC 29410. Use Save and return later to keep a draft and come back with the private link. Applicant privacy notice.
MINIMUM SERVICE STANDARDS — DRIVERS
GENERAL DRIVER GUIDELINES:
UNACCEPTABLE DRIVER FACTORS:
Revised 03/12/2010
ESSENTIAL JOB FUNCTIONS — DRIVER
Type your full legal name in a script style below, or draw your signature. Date is required to Submit.
Complete any that apply. You may enter Local, Regional, and OTR.
Required if current address is less than 3 years.
Add previous address
Penalty includes forfeited bond, collateral and/or points.
(ATTACH SHEET IF MORE SPACE IS NEEDED)
EMPLOYMENT RECORD (ATTACH SHEET IF MORE SPACE IS NEEDED)
Applicants that desire to drive intrastate / interstate commerce must provide the following information on all employers during the previous three years. You must give the same information for all employers you have driven a commercial motor vehicle or taken a DOT drug screen for the seven years prior to the initial three year (total of ten years employment record).
Must list the complete mailing address: street number and name, city, state and zip code. Start with current or most recent employer and list in reverse for the past 10 years. If work history is not that long, list back to first job and annotate in margins that this was your first job.
Add previous employer
If yes, please explain fully below or on a separate sheet of paper. Conviction of a crime is not an automatic bar to employment - all circumstances will be considered.
TO BE READ AND SIGNED BY APPLICANT
I certify that I have read and understand all of this employment application. It is agreed and understood that the employer or his agent may investigate my background to ascertain any and all information of concern to my employment history, whether same is of record or not, and I release employers and other persons herein from all liability for any damages on account of furnishing such information. I understand that, as an applicant for a position with this company, I may be asked to demonstrate that I am capable of performing such tasks which are pertinent to this job. I also understand that if offered a job, it may be conditioned on the results of a physical examination and a drug test.
I further certify that I am a genuine applicant for employment and this application is being submitted solely for the purpose of seeking employment with the employer and for no other reason.
It is also agreed and understood that under the Fair Credit Reporting Act, Public Law 91-508, I have been told that this investigation may include an Investigative Consumer Report, including information regarding my character, general reputation, personal characteristics, and mode of living.
I agree to provide such additional information and complete such examinations as may be required to complete my employment file.
I also understand that misrepresentation or omission of information or fact may result in my rejection or dismissal.
As an applicant to this company for U.S. Dept. of Transportation regulated employment (CDL driver), I understand the company must know certain information up to three years prior to the date of my application. I understand that I have the following rights regarding the investigative information that will be provided to this prospective employer pursuant to 391.23(d)(e): the right to review information provided by previous employer(s); the right to have errors in the information corrected by the previous employer(s) and for that/those previous employer(s) to resend the corrected information to the company; and/or, the right to have a rebuttal statement attached to the alleged erroneous information if the previous employer(s) and I, as the driver, cannot agree on the accuracy of the information.
If hired, I agree to abide by all the rules and policies of the employer.
This certifies that this application was completed by me, and that entries on it and information in it are true and complete to the best of my knowledge. I also certify that I understand my rights regarding the investigative information that will be provided to my prospective employer.
Social Security number is collected by Safety when required. It is not stored on this website.
PHYSICAL EXAMINATION DRUG AND ALCOHOL SCREEN RELEASE FORM
MY INTERMODAL, LLC — 1000 TRIDENT STREET, HANAHAN, SC 29410 — Phone 843-620-0004 — Fax 843-619-2273
I agree to take a DOT required physical by a qualified doctor that is registered on the National Registry of Certified Medical Examiners and drug/alcohol test by a qualified doctor assigned by My Intermodal, LLC. This is to qualify me under Federal Motor Carrier Safety Regulations Section 382 and 391.
I understand I am subject to be tested under the following conditions: Pre-employment, random selection, reasonable cause and post accident.
I hereby release and discharge My Intermodal, LLC, its employees, agents, representatives, doctors, assignees from all direct or implied liability that may arise from the performance of these tests.
DISCLOSURE AND AUTHORIZATION REGARDING BACKGROUND INVESTIGATION FOR EMPLOYMENT PURPOSES
Disclosure
My Intermodal, LLC may request from a consumer reporting agency and for employment-related purposes, a "consumer report(s)" (commonly known as "background reports") containing background information about you in connection with your employment, or application for employment, or engagement for services (including independent contractor or volunteer assignments, as applicable).
HireRight, LLC ("HireRight") will prepare or assemble the background reports for the Company. HireRight is located and can be contacted at 100 Centerview Drive, Suite 300, Nashville, TN 37214, (800) 400-2761, www.hireright.com.
The background report(s) may contain information concerning your character, general reputation, personal characteristics, mode of living, or credit standing. The types of background information that may be obtained include but are not limited to: criminal history; litigation history; motor vehicle record and accident history; social security number verification; address and alias history; credit history; verification of your education, employment and earnings history; professional licensing, credential and certification checks; drug/alcohol testing results and history; military service; and other information.
Authorization
I hereby authorize Company to obtain the consumer reports described above about me.
OTHER DISCLOSURES, ACKNOWLEDGMENTS & AUTHORIZATIONS REGARDING BACKGROUND INVESTIGATION FOR EMPLOYMENT PURPOSES
Investigative Consumer Report: My Intermodal, LLC may request an investigative consumer report about you from HireRight, LLC ("HireRight"), a consumer reporting agency, in connection with your employment, or application for employment, or engagement for services (including independent contractor or volunteer assignments, as applicable). An "investigative consumer report" is a background report that includes information from personal interviews (except in California, where that term includes background reports with or without information obtained from personal interviews), the most common form of which is checking personal or professional references through personal interviews with sources such as your former employers and associates, and other information sources. The investigative consumer report may contain information concerning your character, general reputation, personal characteristics, or mode of living. You may request more information about the nature and scope of an investigative consumer report, if any, by contacting the Company.
Ongoing Authorization: If the Company hires you or contracts for your services, the Company may obtain additional consumer reports and investigative consumer reports about you without asking for your authorization again, throughout your employment or your contract period, as allowed by law.
Additional State Law Notices: Please see the "Additional State Law Notices" for California, Massachusetts, Minnesota, New Jersey, New York, and Washington that are provided below, as applicable. A California disclosure and summary of your rights under California Civil Code Section 1786.22, and a copy of New York Article 23-A, are being provided to you separately.
Summary of Rights under the Fair Credit Reporting Act: A summary of your rights under the Fair Credit Reporting Act is being provided to you separately.
San Francisco Fair Chance Ordinance Official Notice: A copy of the San Francisco Fair Chance Ordinance Official Notice is being provided to you separately.
HireRight Privacy Policy: Information about HireRight's privacy practices is available at www.hireright.com/Privacy-Policy.aspx.
Acknowledgements & Authorization
I acknowledge that I have received and carefully read and understand the separate "Disclosure and Authorization Regarding Background Investigation for Employment Purposes"; and the separate "Summary of Rights under the Fair Credit Reporting Act" that have been provided to me by the Company. I also acknowledge receipt of and that I have carefully read and understand (as applicable), the separate California Disclosure and Summary of Rights under California Civil Code Section 1786.22, the separate New York Article 23-A, and the separate San Francisco Fair Chance Ordinance Official Notice that have been provided to me.
By my signature below, I authorize the preparation of background reports about me, including background reports that are "investigative consumer reports" by HireRight, and to the furnishing of such background reports to the Company and its designated representatives and agents, for the purpose of assisting the Company in making a determination as to my eligibility for employment or engagement for services (including independent contractor or volunteer assignments, as applicable), promotion, retention or for other lawful employment purposes. I understand that if the Company hires me or contracts for my services, my consent will apply, and the Company may, as allowed by law, obtain from HireRight (or from a consumer reporting agency other than HireRight) additional background reports pertaining to me, without asking for my authorization again, throughout my employment or contract period.
I understand that if the Company obtains a credit report about me, then it will only do so where such information is substantially related to the duties and responsibilities of the position in which I am engaged or for which I am being evaluated.
I understand that information contained in my employment (or contractor or volunteer) application, or otherwise disclosed by me before or during my employment (or contract or volunteer 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 understand that the information included in the background reports may be obtained from private and public record sources, including without limitation and as appropriate: government agencies and courthouses; educational institutions; and employers. Accordingly, I hereby authorize all of the following, to disclose information about me to the consumer reporting agency and its agents: law enforcement and all other federal, state and local government agencies and courts; educational institutions (public or private); testing agencies; information service bureaus; credit bureaus and other consumer reporting agencies; other public and private record/data repositories; motor vehicle records agencies; my 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, motor vehicle and accident history; drug/alcohol testing results and history; criminal history; litigation history; military service; professional licenses, credentials and certifications; social security number verification; address and alias history; and other information.
By my signature below, I also promise that the personal information I provide with this form or otherwise in connection with my background investigation is true, accurate and complete, and I understand that dishonesty or material omission may disqualify me from consideration for employment. I agree that a copy of this document in faxed, photocopied or electronic (including electronically signed) form will be valid like the signed original. I further acknowledge that I have received additional state law notices that I have reviewed and read.
Additional State Law Notices
CALIFORNIA: Pursuant to section 1786.22 of the California Civil Code, you may view the file maintained on you by the consumer reporting agency during normal business hours. You may also obtain a copy of this file, upon submitting proper identification and paying the actual copying costs, by appearing at the consumer reporting agency's offices in person, during normal business hours and on reasonable notice, or by certified mail. You may also receive a summary of the file by telephone, upon submitting proper identification and written request. The consumer reporting agency has trained personnel available to explain your file to you, including any coded information, and will provide a written explanation of any coded information contained in your file. If you appear in person, you may be accompanied by one other person, provided that person furnishes proper identification. "Proper identification" includes documents such as a valid driver's license, social security account number, military identification card, and credit cards. If you cannot identify yourself with such information, the consumer reporting agency may require additional information concerning your employment and personal or family history to verify your identity.
HireRight, LLC ("HireRight") will prepare the background report for the Company. HireRight is located and can be contacted at 100 Centerview Drive, Suite 300, Nashville, TN 37214, (800) 400-2761. Information about HireRight's privacy practices is available at www.hireright.com/Privacy-Policy.aspx. Additional California-specific information is set out below.
MASSACHUSETTS: Upon request to the Company, you have the right to know whether the Company requested an investigative consumer report about you and, upon written request to the Company, you have the right to receive a copy of any such report. You also have the right to ask the consumer reporting agency (e.g., HireRight) for a copy of any such report.
MINNESOTA: You have the right in most circumstances to submit a written request to the consumer reporting agency (e.g., HireRight) for a complete and accurate disclosure of the nature and scope of any consumer report the Company ordered about you. The consumer reporting agency must provide you with this disclosure within 5 days after (i) its receipt of your request or (ii) the date the report was requested by the Company, whichever date is later.
NEW JERSEY: You have the right to submit a request to the consumer reporting agency (e.g., HireRight) for a copy of any investigative consumer report the Company requested about you.
NEW YORK: You have the right, upon written request to the Company, to be informed of whether or not the Company requested a consumer report or an investigative consumer report about you. Shown above is the address and telephone number for HireRight, the consumer reporting agency used by the Company. You may inspect and receive a copy of any such report by contacting that consumer reporting agency. A copy of Article 23-A of the New York Correction Law is also provided below.
WASHINGTON STATE: If the Company requests an investigative consumer report, you have the right, upon written request made to the Company within a reasonable period of time after your receipt of this disclosure, to receive from the Company a complete and accurate disclosure of the nature and scope of the investigation requested by the Company. You are entitled to this disclosure within 5 days after the date your request is received or the Company ordered the report, whichever is later. You also have the right to request a written summary of your rights and remedies under the Washington Fair Credit Reporting Act.
Para información en español, visite www.consumerfinance.gov/learnmore o escribe a la Consumer Financial Protection Bureau, 1700 G Street NW, Washington, DC 20552.
A Summary of Your Rights Under the Fair Credit Reporting Act
The federal Fair Credit Reporting Act (FCRA) promotes the accuracy, fairness, and privacy of information in the files of consumer reporting agencies. There are many types of consumer reporting agencies, including credit bureaus and specialty agencies (such as agencies that sell information about check writing histories, medical records, and rental history records). Here is a summary of your major rights under FCRA. For more information, including information about additional rights, go to www.consumerfinance.gov/learnmore or write to: Consumer Financial Protection Bureau, 1700 G Street NW, Washington, DC 20552.
CONSUMERS HAVE THE RIGHT TO OBTAIN A SECURITY FREEZE
You have a right to place a "security freeze" on your credit report, which will prohibit a consumer reporting agency from releasing information in your credit report without your express authorization. The security freeze is designed to prevent credit, loans, and services from being approved in your name without your consent. However, you should be aware that using a security freeze to take control over who gets access to the personal and financial information in your credit report may delay, interfere with, or prohibit the timely approval of any subsequent request or application you make regarding a new loan, credit, mortgage, or any other account involving the extension of credit.
As an alternative to a security freeze, you have the right to place an initial or extended fraud alert on your credit file at no cost. An initial fraud alert is a 1-year alert that is placed on a consumer's credit file. Upon seeing a fraud alert display on a consumer's credit file, a business is required to take steps to verify the consumer's identity before extending new credit. If you are a victim of identity theft, you are entitled to an extended fraud alert, which is a fraud alert lasting 7 years.
A security freeze does not apply to a person or entity, or its affiliates, or collection agencies acting on behalf of the person or entity, with which you have an existing account that requests information in your credit report for the purposes of reviewing or collecting the account. Reviewing the account includes activities related to account maintenance, monitoring, credit line increases, and account upgrades and enhancements.
States may enforce the FCRA, and many states have their own consumer reporting laws. In some cases, you may have more rights under state law. For more information, contact your state or local consumer protection agency or your state Attorney General. For information about your federal rights, contact:
TRUCKING INDUSTRY: 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 HireRight for the purpose of HireRight transmitting such records to the HireRight 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, occurring during 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 HireRight with information concerning items (i) through (vi) above, I also authorize such company to furnish the following information to HireRight, 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. If necessary, attach additional pages, including the date, your name, social security number and signature.
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 as well as the attached FMCSA Notification of Driver Rights and any applicable state law notices; (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; and (vi) facsimile or photographic copies of this authorization are as valid as an original.
FMCSA Notification of Driver Rights (49 CFR 391.23)
In accordance with 49 CFR Part 391.23, you have the following rights:
Drivers who have previous DOT regulated employment history in the preceding three years, and wish to review previous employer-provided investigative information must submit a written request to the prospective employer, which may be done at any time, including when applying, or as late as 30 days after being employed or being notified of denial of employment. The prospective employer must provide this information to the applicant within five (5) business days of receiving the written request. If the prospective employer has not yet received the requested information from the previous employer(s), then the five-business-days deadline will begin when the prospective employer receives the requested safety performance history information. If the driver has not arranged to pick up or receive the requested records within thirty (30) days of the prospective employer making them available, the prospective motor carrier may consider the driver to have waived his/her request to review the records.
Drivers wishing to correct erroneous information in records received must send the request for the correction to the previous employer that provided the records to the prospective employer. The previous employer must either correct and forward the information to the prospective motor carrier employer, or notify the driver within 15 days of receiving a driver's request to correct the data that it does not agree to correct the data. If the previous employer corrects and forwards the data as requested, that employer must also retain the corrected information as part of the driver's safety performance history record and provide it to subsequent prospective employers when requests for this information are received.
Drivers wishing to rebut information in records received must send the rebuttal to the previous employer with instructions to include the rebuttal in that driver's safety performance history.
SAFETY PERFORMANCE HISTORY RECORDS REQUEST — PART 1 (TO BE COMPLETED BY PROSPECTIVE EMPLOYEE)
I hereby authorize previous employers listed on this application to release and forward the information requested concerning my Alcohol and Controlled Substances Testing records within the previous 3 years from the employment application date.
To: Prospective Employer: My Intermodal, LLC — Attention: Celeste Fortner — Telephone: 843-620-0048 — Street: 1000 Trident St — City, State, Zip: Hanahan, SC 29410
In compliance with §40.25(g) and 391.23(h), release of this information must be made in a written form that ensures confidentiality, such as fax, email, or letter. Prospective employer's fax number: 843-619-2273. Prospective employer's email address: CelesteF@myintllc.com
This information is being requested in compliance with §40.25(g) and 391.23.
INSTRUMENT OF WRITTEN CONSENT FOR CDLIS INQUIRY
I, the undersigned commercial driver, hereby authorize My Intermodal, LLC to request or access data pertaining to me within the CDLIS Central Site, to obtain all CDLIS Master Pointer Record data relating to me (CDLIS Data), and to request and obtain my driver record from the jurisdiction identified in the CDLIS Data in accordance with applicable state law and the Driver Privacy Protection Act. I hereby further authorize the disclosure of my CDLIS Data and driver records to My Intermodal, LLC.
MY INTERMODAL, LLC General Consent for Queries of the Federal Motor Carrier Safety Administration (FMCSA) Drug and Alcohol Clearinghouse
I hereby provide consent to My Intermodal, LLC Safety Department to conduct multiple full and limited queries for the duration of my employment of the FMCSA Commercial Driver's License Drug and Alcohol Clearinghouse to determine whether drug or alcohol violation information about me exists in the Clearinghouse. I understand that if the multiple full and limited queries conducted by My Intermodal, LLC's Safety Department indicates that drug or alcohol violation information about me exists in the Clearinghouse, FMCSA will not disclose that information to My Intermodal, LLC Safety Department without first obtaining additional specific consent from me. I further understand that if I refuse to provide consent for My Intermodal, LLC's Safety Department to conduct a multiple full and/or limited query of the Clearinghouse, My Intermodal, LLC's Safety Department must prohibit me from performing safety-sensitive functions, including driving a commercial motor vehicle, as required by FMCSA's drug and alcohol program regulations.
AUTHORIZATION
I hereby authorize My Intermodal, LLC to conduct limited annual queries of the FMCSA's Drug & Alcohol Clearinghouse, to determine if a Clearinghouse record exists for me. This consent is valid from the date shown below until my employment with the above-named municipality ceases or until I am no longer subject to the drug and alcohol testing rules in 49 CFR part 382 for the above-named municipality. I understand that if any full and/or limited query reveals that the Clearinghouse contains information about me, I must grant electronic consent within 24 hours, via the Clearinghouse website, for My Intermodal, LLC to obtain my full Clearinghouse record. Refusal to provide such consent will result in my removal from safety-sensitive duties.
This disclosure and authorization is a stand-alone document as required by FMCSA.
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 My Intermodal, LLC ("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 My Intermodal, LLC ("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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