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 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
* 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. I
understand that consumer reports may be requested from HireRight. These reports may include: previous employer verifications, reason for termination, accidents, driving records, workers compensation
claims, etc. I further understand that such reports may contain information from federal, state or other agencies. 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 The TLC Companies to release any and all information regarding myself to any
of its lessees that TLC may consider assigning me to. 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.
I authorize, per 49 CFR Part 40 of FMCSRs, 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
The TLC Companies participates in E-Verify, which means if you are hired information from your I-9 form will be provided to the Social Security Administration, and if necessary, the
Department of Homeland Security, to confirm work authorization. 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.
Disclosure and Authorization - Consumer Reports
As part of your application for employment or your interest in being qualified as a contractor with The TLC Companies (the "Company"), the Company intends to obtain a consumer report and criminal background
screen from consumer reporting agencies such as HireRight and/or US Information Search. These consumer reports will be used for employment purposes within the meaning of the Fair Credit Reporting Act
(the "FCRA"). To the extent you enter into an employment or contractual relationship with the Company, the Company may periodically obtain updated consumer reports and criminal background screens. Among the
reports that may be procured by the Company are reports from the Pre-Employment Screening Program (PSP) conducted by the Federal Motor Carrier Safety Administration (the information obtained from this program
is hereinafter referred to as a "PSP Report").
As required by the FCRA, this disclosure is to inform you that a consumer report, including information as to character, general reputation, personal characteristics, and mode of living, whichever are
applicable, may be procured from time to time. Such reports may contain public information concerning your driving record, safety record, workers' compensation claims, credit, bankruptcy proceedings,
criminal records, etc. from federal, state and other agencies, which maintain such records. Consumer reports and background checks are conducted only in accordance with state and local laws.
Should the information received in the consumer report be the reason in whole or in part for any adverse action taken against you by the Company, you may obtain a free copy of the consumer report from
the consumer reporting agency so long as the report is requested within 60 days of notification of the adverse action. You have the right to dispute the accuracy or completeness of any information contained
in the consumer report furnished by the consumer reporting agency.
This signed Authorization is my authorization and consent for the Company to procure a PSP report for pre-employment screening only, consumer reports and criminal background reports from a consumer reporting
agency from time to time as required by the Company for employment or contract purposes.
This authorization shall remain on file and shall serve as on-going authorization for the Company to procure consumer and criminal background reports at any time during my employment or contractual
relationship and the qualification process with respect thereto. I understand that, upon termination of my employment or contract for any reason, this authorization shall be destroyed and of no
I hereby certify that I have read the foregoing and understand the contents of this Disclosure and Authorization. I also understand the remedies available to me should I disagree with the Consumer Reporting
Agency with respect to the consumer report.
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 who can perform these essential
functions with or without reasonable accommodations.
These statements/questions pertain only to the essential functions of the job for which you are applying.
For any No answers to questions 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.