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Addresses at which Applicant has resided during the 3 years preceding date application submitted
In Case of Emergency notify:
Previous Employment: Information required by 49 CFR 391.21(b)(10)(11): Names and addresses of applicant's
employers during the 10 years preceding date this application submitted; dates employed by, reason for leaving
employment, whether applicant subject to Federal Motor Carrier Safety Regulations (FMCSRs), and whether job
designated as safely sensitive function in any DOT regulated mode subject to alcohol and controlled substances
testing requirements as required by 49 CFR part 40 for each such employer. Previous employer information is also
needed to comply with 49 CFR 40.25 and 391.23(e)(checking applicant's prior drug/alcohol test records) and/or
required under authority of Sweet Express as part of its application process.
Dates of Employment
License and Permit Information for every State in which Driver held a commercial motor vehicle operator's
license or permit during past 3 years.
List of violations of motor vehicle laws or ordinances (other than parking) of which applicant as convicted or forfeited
bond or collateral during the 3 years preceding date application submitted.
Has any license, permit, or privilege to operate a motor vehicle issued to you ever been:
List all motor vehicle accidents applicant involved in for 3 years preceding date application submitted:
I understand that all Sweet Express employees are employed on an indefinite basis and are subject to termination at any time, with or without notice, with or without prior discipline or warning, and with or without cause. No person other than the President of Sweet Express has authority to offer employment for any specified period or to make any contact contrary to the statement of at will employment. Moreover, no such agreement by the president will be enforceable unless the document in writing, dated, and signed by the President.
This certifies that this application was completed by me, and that all entries on it and information in it are true and complete to the best of my knowledge.
Authorization of Background Investigation
I have carefully read and understand this Disclosure and Authorization form and the attached summary of rights
under the Fair Credit Reporting Act. By my signature below, I consent to preparation of background reports by a
consumer reporting agency such as HireRight, Inc (HireRight), and to the release 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 (including independent contractor 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 additional
background reports pertaining to me, without asking for my authorization again, throughout my employment or
contract period form HireRight and/or other consumer reporting agencies.
I understand the information contained in my employment or contractor application, or otherwise disclosed by me
before or during my employment or contract 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 services.
I hereby authorize all of the following, without limitation, to disclose information about me to the consumer reporting
agency and its agents: law enforcement and all other federal, state and local agencies, learning institutions
(including public and private school, colleges, and universities), testing agencies, information services bureaus,
credit bureaus, record/data repositories, courts (federal, state and local), motor vehicle record agencies, my past or
present 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 history, motor vehicle history,
criminal history, military service, professional credentials and licenses.
By my signature below, i also certify the information I provided on and in connection with this form is true, accurate
and complete. I agree that this form in original, faxed, photocopied or electronic (including electronically signed)
form, will be valid for any background reports that may be requested by or on behalf of the Company.
MANDATORY USE FOR ALL ACCOUNT HOLDERS
IMPORTANT NOTICE REGARDING BACKGROUND REPORTS FROM THE PSP Online Service.
1. In connection with your application for employment with SWEET EXPRESS (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 Perspective 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 Perspective 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 form FMCSA in a decision to not hire you or to make any other adverse employment decision regarding you, the Perspective 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 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 report 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 summary of your rights under the Fair Credit Reporting Act.
The Prospective Employer cannot obtain background reports from FMCSA unless you consent in writing.
If you agree that the Prospective Employer may obtain such background reports, please read the following and sign below:
2. I authorize Sweet Express ("Prospective Employer") to access the FMCSA PreEmployment 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 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. I understand and acknowledge that this release of information may assist the Prospective Employer to make a determination regarding my suitability as an employee.
3.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 http://dataqs.fmcsa.dot.gov. if I am challenging 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 or adjudication.
4. Please note: Any crash or inspection in which you were involved will display on your PSP report. Since the PSP does not report, or assign, or imply fault, it will include all Commercial Motor Vehicle (CMV) crashes where you were a driver or codriver and where those crashes were reported to FMCSA, regardless of fault. Similarly, all inspections, with or without violations, appear, and remain, on a PSP report.
I have read the above Notice Regarding Background Reports provided by Prospective Employer and I understand that if I sign this consent form, Prospective Employer and its employees, authorized agents, and or affiliates to obtain the information authorized above.
The parties agree that signature(s) on this agreement may be delivered by facsimile or electronically in lieu of an original signature and agree to treat facsimile or electronic signatures as original signatures that bind them to this agreement, and authorize Sweet Express or Omni Transport to execute the terms of the agreement.
NOTICE: This form is made available to monthly account holders by NICT 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 provided in paragraphs 1-4 of this document to obtain a prospective Applicant's consent. The language must be used in whole, exactly as provided. The language may be included with other consent forms or language at the discretion of the account holder, provided the four paragraphs remain intact and the
language is unchanged.