Full Application

Request for Driving Record

I, (name below) request that Brands Insurance order a copy of my driving record so that I can be considered for employment by Erwin Brothers, LLC

and forward a copy of my abstract to my potential employer via FAX or E-MAIL. I further authorize Brands Insurance to forward a copy of my driving abstract to the insurance company that underwrites the coverage for my protentional employer.

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 ErwinBrothers Specialized Trucking (“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 ErwinBrothers Specialized Trucking (“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

Attention CDL Drivers:

The DOT Drug & Alcohol Clearinghouse arrives January 6, 2020

What is it? An online database providing employers, licensing agencies, and enforcement officers with real-time information about truck and bus drivers who have violated DOT drug or alcohol testing rules. Employers must check the Clearinghouse when hiring each new CDL driver and every year for existing CDL drivers like you. The Clearinghouse will affect you in several ways: 

1. You will need to register on the Clearinghouse website (available Fall 2019) in order to comply with item #2 below. Registration is optional unless you switch employers or have a DOT drug or alcohol violation. Registration will give you free access to your own Clearinghouse record. clearinghouse.fmcsa.dog.gov
2. You will need to go to the Clearinghouse to grant electronic consent whenever your employer is required to purchase a full Clearinghouse report on you. You will not be allowed to continue operation a commercial motor vehicle (CMV) or perform other safety-sensitive duties if you refuse to grant this consent. (§ 382.703 (c))
3. You will need to sign a separate consent form (annually or one-time) to allow your employer to obtain "limited' Clearinghouse reports that indicate whether there is information about you in the Clearinghouse (if there is, then a full report will be required - see #2 above) (§ 382.701(b))
4. If you commit any of the following DOT violations or complete any of the following steps after January 6, 2020, it will be reported to the Clearinghouse:
   1. Any verified positive, adulterated, or substituted drug test
   2. Any confirmed alcohol test of 0.04 or higher
   3. Any refusal to submit a DOT-required test
   4. Any verified and documented "actual knowledge" that you violated dug/alcohol rules:
      1. Any on-duty alcohol use, including citation for DUI/DWI while driving a CMV
      2. Any alcohol use within 4 hours before going on duty
      3. Any alcohol use within 8 hours of an accident or before a post-accident test is complete (whichever occurs first)
      4. Any prohibited drug use while on duty
   5. Successful completion of the return-to-duty process following treatment*
   6. Any negative return-to-duty test*
   7. Successful completion of follow-up testing*  (*Only reported if the underlying violation occurred after January 6, 2020)
5. You will be notified whenever information about you in the Clearinghouse is added, removed or revised. You can specify how you want to be contacted when you register.

I hereby acknowledge recieving education information about the CDL Drug & Alcohol Clearinghouse as required under §382.601(b)(12).

Thank you for applying for a driving position with our company. We are committed to providing the highest quality of service to our customers. In order to do this, we are seeking the most qualified individuals. The following is a list of minimum qualifications required by our company. Please read carefully and sign in the space provided if you meet these qualifications. If you meet these qualifications, an in-depth background investigation will be conducted, and a hiring decision will be made.

1. Must be at least twenty-three (23) years of age.
2. Must have at least one (2) year of verifiable all-weather tractor-trailer experience in the past three (3) years if applying for a tractor-trailer position. Must have at least one (2) year of verifiable all-weather straight truck experience in the past three (3) years if applying for a straight truck position.
3. Must not have had a D.W.I or D.U.I conviction in the past five (5) years. There can be no current pending D.W.I or D.U.I charges.
4. No major chargeable accidents in the past three (3) years while driving a commercial motor vehicle.
5. No more than three (3) minor or two (2) major moving violations in the last three (3) years.
6. No more than three (3) minor accidents in the last five (5) years.
7. Possess only one (1) driver’s license and it must be from the state of residence.
8. Fill out the application completely to include ten (10) years of employment history.
9. You will be required to provide a urine sample to be used for our Federally Mandated Drug Screening program. All new and re-hire applicants must pass this drug screen before being employed.

I, the undersigned, meet the above qualifications and further agree to abide by all company policies. Misrepresentation on the application will result in immediate termination.

I hereby authorize release of information from my Department of Transportation regulated drug & alcohol testing records by my previous employer, listed below, to the POTENTIAL motor carrier. This release is in accordance with DOT Regulation 49 CFR Part 40, Section 40.25. I understand that information to be released by my previous employer, is limited to the following DOT-regulated testing items: 1. Alcohol tests with a result of 0.04 or higher; 2. Verified positive drug tests; 3. Refusals to be tested; 4. Other violations of DOT agency drug and alcohol testing regulations; 5. Information obtained from previous employers of a drug and alcohol rule violation; 6. Documentation, if any, of completion of the return-to-duty process following a rule violation.

I further authorize my former employer to release my safety performance history information to my prospective employer for investigation purposes as required by FMCSR 391.23, 382.405 (f) & 382.413(b) for the 3 years preceding this release. You are released from any and all liability that may result from furnishing such information. A photocopy of this release shall be as valid as the original.

Erwin Brothers, 10501 SR118, Ansonia, OH 45303

In compliance with Federal and State equal opportunity laws, qualified applicants are considered for all positions without regard to race, religion, sex, national origin, age, marital status, or non-job related disability.

TO BE READ AND SIGNED BY APPLICANT

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:

• Review information provided by previous employers
• Have errors in the information corrected by previous employers and for those previous employers to re-send the corrected information to the prospective employer, and
• Have a rebuttal statement attached to the alleged erroneous information, if the previous employer(s) and I cannot agree on the accuracy of the information
  

Previous Addresses for the past three (3) years

Note: Company policy states that the applicant must provide a complete 10 year work history and account for all gaps in jobs prior to being considered for employment. 

Employment History

Please list starting with the most recent employer

*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 and/or unemployment must be explained.

Commercial Driver's License Information

Collisions

Please list all motor vehicle collisions in which you were involved (both commercial and private vehicle) during the past three years prior to the application date. 

Traffic Convictions and Forfeitures

Please list all traffic convictions an/or forfeitures (Both commercial AND private vehicle) for the past three years (Other than parking).

Driving Experience

Education

General

Must be Read and Signed by the Applicant 

• 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 ls 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 11, 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 lo 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 DAC Services, Tulsa, Oklahoma. that will include information as to my character, work habits, performance, and experience, along with reasons for termination of past employment obtained from previous employer. Further, I understand that you will ho 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 DAC 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 lo 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 DAC, and agree that such information which DAC has or obtains, and my employment history with you, if I am hired, will be supplied by DAC to other companies which subscribe to DAC's services. 
• IF HIRED BY YOU, I FURTHER CONSENT TO YOUR FURNISHING TO DAC 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 DAC'S FURNISHING SUCH INFORMATION IN THE FUTURE TO OTHER COMPANIES WHICH SUBSCRIBE TO DAC'S SERVICES FROM WHICH I MAY BE SEEKING EMPLOYMENT, AND TO INSURANCE COMPANIES OR THEIR AGENTS IN CONNECTION WITH ISSUANCE OR MAINTENANCE OP INSURANCE COVERAGE. 
• Too 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 given are true and complete to the best of my knowledge.