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Application for Employment - Driving Record Authorization & Background Check Release

Minimum Driver Qualification Information

Oldenbroek Trucking LLC 4544 48th Ave - Suite B, Hudsonville, MI 49426

The purpose of this document is to determine whether or not the driver is qualified to operate motor carrier equipment according to the requirements of the Federal Motor Carrier Safety Regulations and the Company named above.

Instructions to Driver

Please answer all questions. If the answer to any question is "No" or "Not Applicable" do not leave the item blank, but please indicate "N/A" or "None."

Today's Date:

Position Applying For (choose one): Contractor Driver Contractor's Driver

Applicant Name:

Phone Number: Emergency Phone Number:

Date of Birth: Age*:

Social Security Number:

List Any Previous Names/Aliases/Also Known As:

*The Age Discrimination of Employment Act of 1967 prohibits discrimination on the basis of age with respect to individuals who are at least 40 years of age.

Physical Exam Expiration Date:

Current & Past Three Years Previous Addresses:

Current Address:

From: To:

Previous Address 1:

From: To:

Previous Address 2:

From: To:

Previous Address 3:

From: To:

Have you worked for Oldenbroek Trucking before?

Yes

If "Yes" provide dates From: To:

Reason for Leaving:

Education History

Highest Grade Completed - Grade School:

Highest Grade Completed - College:

Highest Grade Completed - Post Graduate:

Employment History

Give a complete record of all employment for the past three years, including any unemployment or self employment, and all commercial driving experience for the past ten years.

Present or Last Employer:

Dates Employed From: To:

Position Held:

Employer Address:

Employer Phone:

Were you subject to the FMCSRs* while employed here?

Yes

Was your job designated as a safety-sensitive function in any DOT-Regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40?

Yes

Reason for leaving:

Previous Employer:

Dates Employed From: To:

Position Held:

Employer Address:

Employer Phone:

Were you subject to the FMCSRs* while employed here?

Yes

Was your job designated as a safety-sensitive function in any DOT-Regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40?

Yes

Reason for leaving:

Previous Employer:

Dates Employed From: To:

Position Held:

Employer Address:

Employer Phone:

Were you subject to the FMCSRs* while employed here?

Yes

Was your job designated as a safety-sensitive function in any DOT-Regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40?

Yes

Reason for leaving:

Previous Employer:

Dates Employed From: To:

Position Held:

Employer Address:

Employer Phone:

Were you subject to the FMCSRs* while employed here?

Yes

Was your job designated as a safety-sensitive function in any DOT-Regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40?

Yes

Reason for leaving:

Previous Employer:

Dates Employed From: To:

Position Held:

Employer Address:

Employer Phone:

Were you subject to the FMCSRs* while employed here?

Yes

Was your job designated as a safety-sensitive function in any DOT-Regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40?

Yes

Reason for leaving:

*The Federal Motor Carrier Safety Regulations (FMCSRs) apply to anyone who operates a motor vehicle on a highway in interstate commerce to transport passengers or property when the vehicle : (1) has a GVWR or weighs 10,001 pounds or more, (2) is designed or used to transport nine or more passengers, or (3) is of any size, used to transport hazardous materials in a quantity requiring placarding.

Driving Experience & Class of Equipment

Straight Truck Yes No

If Yes, Approximate Number of Total Miles Driven:

Dates Driven From: To:

Tractor & Semi-Trailer Yes No

If Yes, Approximate Number of Total Miles Driven:

Dates Driven From: To:

Tractor-Two Trailers Yes No

If Yes, Approximate Number of Total Miles Driven:

Dates Driven From: To:

Tractor-Three Trailers (Triples) Yes No

If Yes, Approximate Number of Total Miles Driven:

Dates Driven From: To:

Any Other Class of Equipment? Yes No

Approximate Number of Total Miles Driven:

Dates Driven From: To:

Approximate Number of Total Miles Driven:

Dates Driven From: To:

List all states operated in, for the last five years:

List all special courses/training completed:

List any Safe Driving awards you hold and from whom:

Accident Record Past Three Years

Yes - Details Below No Accidents to Report

Date of Accident:

Nature of Accident:

Accident Location:

Number of Fatalities: Number of Injured:

Date of Accident:

Nature of Accident:

Accident Location:

Number of Fatalities: Number of Injured:

Date of Accident:

Nature of Accident:

Accident Location:

Number of Fatalities: Number of Injured:

Date of Accident:

Nature of Accident:

Accident Location:

Number of Fatalities: Number of Injured:

Traffic Convictions and Forfeitures Past Three Years (other than parking violations)

Yes - Details Below No Traffic Convictions to Report

Date: Location:

Charge:

Penalty:

Date: Location:

Charge:

Penalty:

Date: Location:

Charge:

Penalty:

Current & Past Five Years Driver's Licenses Held:

Expiration Date:

A. Have you ever been denied a license, permit or privilege to operate a motor vehicle?

Yes

B. Has any license, permit or privilege ever been suspended or revoked?

Yes

C. Is there any reason you might be unable to perform the functions of the job for which you have applied (as described in the job description)?

Yes

D. Have you ever been convicted of a felony?*

Yes

If the any of the answers to A, B, C or D is "Yes" please provide details in the space below:

*Disclosure of this information does not automatically exclude the driver from consideration.

Release for Limited Query of Federal Motor Carrier Safety Administration's Commercial Driver's License Drug and Alcohol Clearinghouse

I hereby provide consent to Oldenbroek Trucking LLC to conduct a limited query 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.

Yes

I also understand that a query will be conducted on an annual basis as well, and I am authorizing Oldenbroek trucking LLC to conduct that query once per year for the duration of my contract.

Yes

I understand that if the limited query conducted by Oldenbroek Trucking LLC indicates that drug or alcohol violation information about me exists in the Clearinghouse, FMCSA will not disclose that information to Oldenbroek Trucking without first obtaining additional specific consent from me.

Yes

I further understand that if I refuse to provide consent for Oldenbroek Trucking LLC to conduct a limited query of the Clearinghouse, Oldenbroek Trucking LLC must prohibit me from performing safety-sensitive functions, including driving a commercial motor vehicle, as required by FMCSA’s drug and alcohol program regulations.

Yes

Driving Record Authorization, Background Check and Release

I give permission to Oldenbroek Trucking LLC through its agents, to conduct an appropriate background investigation of me and prepare a report. This may be used as a factor in determining my eligibility for employment in transportation, for promotion, for retention or to maintain DOT Compliance, as governed by the Fair Credit Reporting Act Public law 91-508 and FMCSA Section 391. I understand this report may include information from personal interviews about my character, general reputation, personal characteristics and mode of living as well as public and private sources including but not limited to the acquisition of criminal records, employment records, school records, driving records, driving records or abstracts, FMCSA Drug & Alcohol Clearinghouse, etc. I authorize all persons who may have information relevant to this investigation to disclose it to Oldenbroek Trucking LLC and its agents, and I release from any liability on account of such disclosure. I hereby further authorize that a photocopy of this authorization may be considered as valid as an original. This authorization shall remain on fire and in effect as an on-going authorization, for as long as I am employed (contracted), for queries and reports as needed to maintain DOT compliance.

Yes No

Applicant Name: Date

Important Disclosure Regarding Background Reports from the PSP Online Service

In connection with your application for employment with Oldenbroek Trucking 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.

Authorization

If you agree that the Prospective Employer may obtain such background reports, please read the following and sign below:

I authorize Oldenbroek Trucking 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.

Yes No

Applicant Name: Date

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.

To Be Read and Signed by Driver

It is agreed and understood that any misrepresentation given on this document shall be considered an act of dishonesty.

It is agreed and understood that the motor carrier or his agents may investigate my background to ascertain any and all information of concern to commercial driving record, whether same is of record or not. I release the employers and persons named herein from all liability for any damages on account of their furnishing such information.

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 investigating Consumer Report, including information regarding my character, general reputation, personal characteristics, and mode of living.

This certifies that the above information was completed by me, and that all entries on it and information in it are true and complete to the best of my knowledge.

Yes No

Applicant Name:

Leave this empty:

Your legal name

Your email address

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Timestamp

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June 30, 2023 4:06 pm EDT

Application for Employment - Driving Record Authorization & Background Check Release Uploaded by Oldenbroek Trucking - [email protected] IP 50.245.104.73