In compliance with Federal and State Equal Employment Opportunity Commission (EEOC) laws, qualified applicants are considered for all positions without regard to race, color, religion, sex, national origin, age, marital status, or non-job-related disability. All questions on this form must be completed.
All drivers must provide the following information on all employers during the preceding three years. List complete address and phone number for each employer. If applying for a position driving a commercial motor vehicle*, you must also provide an additional seven years of employment information for those employers for whom the applicant operated such vehicle (a total of 10 years). Your present and previous employers will be contacted for the purpose of investigating your safety performance history as required by 391.23 of the FMCSRs.
* Includes vehicles having a GVWR of 26,001 lbs or more, vehicles designed to transport 16 or more passengers, or any size vehicle used to transport hazardous materials in a quantity requiring placarding.
Experience and Qualifications - Driver
This certifies that I completed this application, and that all entries on it and information in it are true and complete to the best of my knowledge.
I authorize you to make such investigations and inquiries of my personal, employment, financial and other related matters as may be necessary in arriving at an employment decision. Specifically, I understand that consumer reports may be requested from DAC Services. These reports may include the following types of information: previous employers, dates of service, reason for termination, accidents, etc. I further understand that such reports may contain from federal, state or other agencies, information concerning my driving record, criminal record, workers’ compensation claims, etc. I hereby release employers, schools, healthcare providers and other persons from all liability in responding to inquiries and releasing information in connection with my application. I further authorize TLC to release any and all information regarding myself to any of its lessees that TLC may consider assigning me to. I also authorize any motor carriers to whom I may be assigned to release copies of my DOT long form physicals and drug test results to TLC.
You have the right to review information provided to us by your previous employers and have any errors in such information corrected by your previous employer as stated in section 391.23 (i) of the FMCSRs. Should you wish to review this information you must submit a written request to us, your prospective employer, as stated in section 391.23 (i) of the FMCSRs.
In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the Company.
RELEASE & CONSENT FORM HireRight SERVICES
PART 1 – DOT DRUG AND ALCOHOL RELEASE
I authorize, per 49 CFR Part 40, the release of information from my DOT regulated drug and alcohol testing records by my previous employers to HireRight for the sole purpose of transmitting such records to The TLC Companies and its representatives/agents/clients. I authorize the release of the following information concerning DOT drug and alcohol testing violations including pre-employment tests during the past three years: (i) alcohol tests with a result of 0.04 or higher; (ii) verified positive drug tests; (iii) refusals to be tested (including verified adulterated or substituted results); (iv) other violations of DOT drug and alcohol testing regulations; (v) information obtained from previous employers of drug and alcohol rule violation(s); and (vi) documents, if any, of completion of return-to-duty process following a rule violation. I hereby authorize my worksite employer to submit copies of my current and future drug test results to the TLC Companies. This authorization shall expire if and when my worksite employer is no longer a client of the TLC Companies. The information I have authorized HireRight to review involves tests required by the DOT. If any carrier/company/school for whom I was previously employed furnishes HireRight with information concerning items (i) through (vi) above, I also authorize that carrier/company/school to release and furnish the dates of my negative drug and/or alcohol tests with results below 0.04 during the three year period and the name and phone number of any substance abuse professionals who evaluated me during the past three years.
PART 2 – CONSUMER REPORT DISCLOSURE AND RELEASE
In connection with your employment or application for employment (including contract for services), consumer reports may be requested from HireRight or other Consumer Reporting Agencies ("CRA"). These reports may include the following types of information: names and dates of previous employers, reason for termination of employment, credit reports work experience, accidents, academic history, professional credentials, and drug/alcohol use. Such reports may contain public record information concerning your driving record, workers' compensation claims, credit, bankruptcy proceedings, criminal records, etc. from federal, state and other agencies which maintain such records; as well as information from CRA concerning previous driving record requests made by others from such state agencies and state provided driving records. If final adverse action is taken against you based upon a background report, TLC will notify you that the action has been taken and that the background report was the reason for the action.
I authorize TLC to contact any organization or individual that I have listed on my employment application or resume or mentioned in job interviews and obtain from them any relevant information about my job qualifications, including my experience, skills and abilities. I understand that I am consenting to the release of safety performance information including crash data from the previous five (5) years and inspection history from the previous three (3) years, as well as any reference-related information about me held or known by my former employers, supervisors, and co-workers. In addition I consent to the release of any information about my education, experience, abilities, or work-related characteristics or traits held or known by other organizations or individuals, including schools and educational institutions, professional or business associates, and friends and acquaintances that TLC might contact in the course of conducting a reference check or background investigation of my suitability for employment. You have the right to make a request to CRA, upon proper identification, to request the nature and substance of all information in its files on you at the time of your request, including the sources of information and the recipients of any reports on you that CRA previously furnished within the three-year period preceding your request. The TLC Companies can be contacted by mail at 325 S. Calumet Road, Suite 1, Chesterton, IN, 46304 or by phone at 1-800-926-8440.
I AUTHORIZE, WITHOUT RESERVATION, ANY PARTY OR AGENCY CONTRACTED BY CRA, TO FURNISH THE ABOVE-MENTIONED INFORMATION. THIS AUTHORIZATION DOES NOT APPLY TO DRUG AND ALCOHOL INFORMATION OBTAINED UNDER PART 1. I hereby consent to your obtaining the above information from CRA, and I agree that such information which CRA has or obtains, and my employment history (not Drug and Alcohol information without a specific consent from me) with you if I am hired, will be supplied by CRA to other companies which subscribe to CRA. I hereby authorize procurement of consumer report(s). If hired or contracted this authorization, for Part 2 reports only, shall remain on file and shall serves as ongoing authorization for you to procure consumer reports at any time during my employment or contract period. I understand and acknowledge that this release of information can involve my qualifications, performance, credentials, or other characteristics or factors affecting my suitability for employment with TLC. Specifically, I am authorizing the release of any information about my performance, experience, capability, attitude, specific events, or other work-related characteristics that currently are in the possession of the requested organizations or their managers or representatives.
In exchange for the TLC's consideration of my employment application, I agree not to file or pursue any complaints, claims; or legal actions of any kind against any organization or individual that provides work-related information about me to TLC or its agents in accordance with the terms and intent of this release. I also agree not to file or pursue any complaints, claims, or legal actions against TLC or any of its employees, representatives, or agents arising out of their efforts to obtain work-related information about me.
I have read the above Consumer Report Disclosure and Release provided to me by TLC and I understand that if I sign this consent form, TLC and /or any entity it retains to obtain such background reports may obtain reports of my credit, driving, and/or criminal background history in addition to information regarding my background, references, education, specific events, and past employment. I hereby authorize TLC, its employees, agents, and affiliates to obtain the information authorized above.
The following are physical requirements pertaining to the job(s) for which you are applying. These bona fide physical requirements are essential functions of the job and are in addition to the skill, certification, years of experience and other qualifications required to perform the job(s) for which you have applied.
Please be aware that all persons may be required to furnish health condition information, and if necessary, submit to an examination by a company-designated physician. This information will be used to determine appropriate job placement. It shall not be used to disqualify an otherwise qualified person who may have a mental or physical disability.
These statements/questions pertain only to the essential functions of the job for which you are applying.
For any No answers to questios 1-8 above, please explain:
Prompt and reliable attendance is a job requirement. I understand that any misstatement, omission, falsification, or misrepresentation of fact on this form is grounds for withdrawal of the conditional job offer or termination of employment if already employed.
Complete application and review for accuracy before clicking submit. Once the application has been submitted it cannot be edited but may be printed for review.
