Work History: Please list current, or most recent employment first
Important Notice Regarding Background Reports From The PSP Online Service
In connection with your application for employment with Gary Blick Trucking, Inc. (Prospective Employer), it may obtain one or more reports regarding your driving and safety inspection history from the Federal Motor Carrier Safety Administration (FMCSA). If the Prospective Employer uses any information it obtains from FMCSA in a decision not to 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. 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:
I authorize Gary Blick Trucking, Inc. (“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 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.
I understand and acknowledge that this release of information can involve my qualifications, performance, credentials, or other characteristics or other factors affecting my suitability for employment with Gary Blick Trucking, Inc. 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 any of its employees, representatives, or agents arising out of their efforts to obtain work-related information about me.
I have read the above Notice Regarding Background Reports provided to me by Prospective Employer and I understand that if I sign this consent form, 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.
I hereby authorize Gary Blick Trucking, Inc. and its employees, agents, and affiliates to obtain the information authorized above.
Controlled Substance Testing Consent Form
As part of my application for employment as a driver of a commercial motor vehicle for Gary Blick Trucking, Inc., I consent to a pre-employment drug/alcohol test as required by Federal Motor Carrier Safety Regulations, part 382.301.
I understand that if I test positive for any controlled substance or alcohol, I will not be offered employment. (Controlled substance means, those substances identifies in part 40.85 of the Federal Motor Carrier Safety Regulations).
I consent to the release of my test results received by the drug testing organization currently being used by Gary Blick Trucking Inc., as the representative of the Medical Review Officer, to management officials of Gary Blick Trucking, Inc. and understand that they will hold the test results in confidence.
I further consent to Gary Blick Trucking Inc., to contact former employers for whom I have worked as a commercial vehicle operator for the past 3 years for the purpose of verifying whether I have tested positive for controlled substances or alcohol, or have refused to test when requested to do so.
I understand that the collection, testing and reporting of my specimen will be done in accordance with Federal Motor Carrier Safety Regulations, part 382.105 and the provisions of part 40 of this title that address alcohol or controlled substances testing. If I am taking any prescription medication at the time of my pre-employment controlled substance/alcohol test, I will be given an opportunity to discuss with an MRO if my test comes back positive for any controlled substance.
Official Disclosure Statement:
I certify that I personally completed this application and that all of the information is true and correct to the best of my knowledge.
Authorization to Release Records
I authorize the carrier subscribers indicated on this application to do a complete background investigation in accordance with state and federal laws. I authorize my previous employers to release any information requested by these carrier subscribers and hold them harmless of all liability from the release of said information.
I hereby request and authorize to cause to be conducted, at any time, an investigation of my background for employment purposes, which may include, but is not limited to, any information relating to my character, general reputation, personal characteristics, criminal history, past work experience, educational background, alcohol or drug test results, or failure to submit to an alcohol or drug test, or any other information about me which may reflect upon my potential for employment gathered from any individual, organization, entity, agency, or other source which may have knowledge concerning any such items of information. I have completed this application of my own free will and hold harmless of all liability all companies, agents and associated parties for the use of this application.
I authorize you to make such investigations and inquiries of my personal, employment, financial or medical history and other related matters as may be necessary in arriving at an employment decision. (Generally, inquiries regarding medical history will be made only if and after a conditional offer of employment has been extended.) I hereby release employers, schools, health care providers and other persons from all liability in responding to inquiries and releasing information in connection with my application.
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 understand that I have the right 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.
In connection with your application for employment (including contract for services), understand that consumer reports or investigative consumer reports which may contain public record information may be requested or made on you including consumer credit, criminal records, driving record, education, prior employer verification, workers compensation claims and others. These reports will include experience information along with reasons for termination of past employment. Further, understand that information from various Federal, State, local and other agencies which contain your past activities will be requested. A consumer report containing injury and illness records and medical information may be obtained only after a tentative offer of employment has been made.
By signing below, you hereby authorize without reservation, any party or agency contacted by this employer to furnish the above mentioned information. You further authorize ongoing procurement of the above mentioned reports at any time during your employment (or contract). You also agree that a fax or photocopy or this authorization with your signature be accepted with the same authority as the original
You hereby authorize and request, without any reservation, any present or former employer, school, police department, financial institution, division of motor vehicles, consumer reporting agencies, or other persons or agencies having knowledge about you to furnish Compliance Safety Systems with any and all background information in their possession regarding you, in order that you employment qualifications may be evaluated.
You have the right to make a request of Compliance Safety Systems, upon proper identification and the payment of any legally permissible fees, for the information in its files on you at the time of your request.
For California, Minnesota or Oklahoma applicants only, if you would like to receive a copy of the consumer report, if one is obtained, please check this box. If checked and you are a California applicant, a copy of the consumer report will be sent within three (3) days of the employer receiving a copy of the consumer report.
For California applicants only, if public record information about your character, general reputation, personal characteristics, and mode of living is obtained without using a consumer reporting agency, you will be supplied a copy of the public record information within seven (7) days of the employer's receipt unless you check this box where you hereby waive your right to obtain a copy of the consumer report.