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 after a conditional offer of employment has been extended.) I hereby release employers, schools, healthcare providers and other persons form all liability in responding to inquiries and releasing information in connection with my application.
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 regulation of the Company.
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 investing my safety performance history as required by 49 CFR 391.23(d) and (e). I understand that I have the right to:
List your addresses of residency for the past 3 years.
All driver applicants to drive in interstate commerce must provide the following information on all employers during the preceding 3 years. List complete mailing address, street number, city, state, and zip code.
Applicants to drive a commercial motor vehicle2 in intrastate or interstate commerce shall also provide an additional 7 years’ information on those employers for whom the applicant operated such vehicle.
(NOTE: List employers in reverse order starting with the most recent.)
1 - Include vehicles having a GVWR of 26,001 lbs. or more, vehicles designed to transport 16 or more passengers
(including the driver), or any size vehicle used to transport hazardous materials in a quantity requiring placecarding.
* - The Federal Motor Carrier Safety Regulations (FMCSRs) apply to anyone operating a motor vehicle on a highway in interstate commerce to transport property when the vehicle: (1) weighs or has a GVWR or 10,001 pounds or more, (2) is designed or used to transport more than 8 passengers (including the driver), OR (3) is of any size and is used to transport hazardous materials in a quantity requiring placecarding.
Accident record for past 3 years or more. List most recent first. (Please list ALL regardless of fault)
Nature of Accident - Head-on, rear-end, upset, etc.
Traffic convictions and forfeitures for the past 3 years (Other than parking violations)
Driver licenses or permits held in the past 3 years
Select highest grade completed for each.
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.
I understand that AIP Logistics, INC. is a drug-free workplace and that a drug test is a condition of employment.
I agree that if I am offered and accept a position with the company that I will be required to take a urine test to screen for the use of illegal drugs, including medically-prescribed marijuana.
I acknowledge that I have been informed of the scope of the test, including which drugs are being screened for, as well as the sample collection procedure. I hereby consent to this test.
Furthermore, I am aware that these results will become part of my employment record and that positive results can affect whether I am hired. I hereby authorize the release of the test results to AIP Logistic, INC.
I understand that as a result of making an application for employment, AIP Logistics (the “Company”), its officers, agents, representatives, or its duly authorized employees, may request, and I also authorize and request, each former employer and each person, firm, or corporation which I have given as a reference to furnish any information that may be sought by the Company concerning me and my work, my habits, character, or skill, and I hereby waive any privileges and release the Company and all referring entities from any liability involved in providing this information.
I further authorize the Company, and its officers, agents, representatives, its duly authorized employees or any third party retained by the Company to make any lawful examination of my criminal record and credit history, and I release any and all individuals connected therewith, from all liability in providing such information. The information solicited may include in-depth information about your character, general reputation, personal characteristics, mode of living, and your criminal, driving and work history, among other things.
I understand that I have the right to request further disclosures regarding the nature and scope of the report(s) solicited by the Company and, upon my request to the Company, to receive a written summary of my legal rights as they pertain to such reports. I authorize the Company to obtain the reports referenced herein at any time in the future so long as I am an employee of the Company.
I hereby authorize American Industrial Partners (hereinafter “Company”) and its designated agents and representatives to investigate my background for employment, promotion, or retention as an employee. I understand that the scope of the investigation may include, but is not limited to, contacting and investigating my former and current employers, personal references, educational institutions where I enrolled, reviewing my criminal history records, sexual offender’s list, motor vehicle records, license verification, and my credit history. I authorize Company to use any and all information acquired to make decision regarding my employment, which may be disclosed to third parties.
I hereby authorize the complete release, without reservation, of the described records, information, or data pertaining to me which any individual, company, firm, corporation, or public agency may have. I authorize the full release of this information throughout the duration of my employment with Company.
I understand that as part of the interview process, Company requires all applicants to disclose pertinent data concerning previous work history, police and criminal records, and educational information and activities. I understand and agree that if any material facts are discovered which differ from those facts stated by me on my employment application, at my interview, or at any time prior to my commencing employment at Company (if I am offered a position with Company), I will not be offered the job. Furthermore, I understand and agree that if material facts are later discovered which are inconsistent with or differ from facts I furnished before taking the job that the Company will discipline me, which may include immediate discharge without warning. I further understand that I have the right to request disclosures regarding the nature and scope of the report(s) solicited by Company and, upon my request to Company, to receive a written summary of my legal rights as they pertain to such reports.
The cost of this investigation will be paid by Company. Nonetheless, I hereby, release and forever discharge and hold Company and its subsidiaries and affiliated companies, agents and employees, as well as the third parities supplying such information, harmless form any and all claims, demands, judgments and legal fees arising out of or in connection with this investigation, the results, or any lawful use of the results or disclosure thereto.
In connection with your application for employment with __AIP Logistics______ (“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.
If you agree that the Prospective Employer may obtain such background reports, please read the following and sign below:
I authorize _____AIP Logistics________ (“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.
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.