street address city state zip - whimsytrucking.com · [f the answer to either a or b is yes, give...

COMPANY NAME WHIMSY INC. _ Location: Region/District/Branch.

COMPANY ADDRESS 1901 S. BUSSE RD. _MOUNT PROSPECT IL _60056Street City State Zip

TO BE READ AND SIGNED BY APPLICANTI authorize you to make such investigations and inquiries of my pBrsonal, employment, financial or medica! history and other related matters as may be necessary in arriving at anemployment decision. (Generally, inquiries regarding medical history wili be made only if and after a conditionai 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.

!n the event of employment, ! understand that false or misleading information given in my application or interview(s) may result in discharge. I understand, also, that I am required toabide by al! rules and reguiations 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 investigating my safetyperformance history as required by 49 CFR 391 -23(d) and (e). I understand that i have the right to:

Review information provided by current/previous employers;

• Have errors in the information corrected by previous emptoyers and for those previous employers to re-send the corrected information to the prospective employer; anc!

a Have a rebuttal statement attached to the alleged erroneous information, if the previous employer(s) and t cannot agree on the accuracy of the information."

Signature_ DateNAME,

Last First Middle

Social Security Number Phone Number Date of Birth Hire Date

ADDRESSStreet City State Zip Number of Years

PAST 3 YEARRESIDENCY Street City State Zip Number of Years

Street City State Zip Number of Years

Employment History(Use Additional Employment History Information form if necessary)

AH applicants wishing to drive in interstate commerce must provide the foliowing information on al! employers during the preceding three years. You must give the same informationfor ail employers for whom you have driven a commercial vehicle seven years prior to the initial three years (total of ten year employment recorci).

You are required to list the complete mailing address: street number and name. city. state and zip code.

CURRENT OR LAST EMPLOYER: Name_ Phone Number (_)Street Address.. __.._.. ___ City^-^^^____^-^-^-^_-^-__-^ ^ ^ State_ Zip

Position Heid _ From — -..- - ^- -_-_- To(monlh/year) (month/year)Reasons for Leaving

Were you subject to the Federal Motor Carrier Safety Regulations** while empioyed? t Yes I No

Was your job designated as a safety-sensitive function in any DOT-reguiated mode subject to the drug and alcohol testing requirements of49 CFR Part 40? ~i Yes ~1 No^ACCOUNT FOR PERIOD BETWEEN JOBS - Inciude dates (month/year) and reason

SECOND LAST EMPLOYER: Name_ Phone Number (_)Street Address_ City_ State_ ZipPosition Held _ From. ^.^ , To(month/year) (month/year)Reasons for LeavingWere you subject to the Federal Motor Carrier Safety Regulations** while employed? I Yes I NoWas your job designated as a safety-sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirements of49 CFR Part 40? ~"1 Yes 1 No*ACCOUNT FOR PERIOD BETWEEN JOBS - Include dates (month/year) and reason

THIRD LAST EMPLOYER: Name _ Phone Number (_)Street Address, City, State_ Zip

Position Held -^ . - —-- —-- - - . - - . From _ To(month/year) (month/year)

Reasons for Leaving

Were you subject to the Federal Motor Carrier Safety Regulations** while empioyed? !_ Yes E NoWas your Job designated as a safety-sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirements of49 CFR Part 40? j Yes ~1 No*ACCOUNT FOR PERIOD BETWEEN JOBS - Include dates (month/year) and reason

*Any gaps in empioyment and/or unemployment must be explained.

**The Federal Motor Carrier Safety Regulations apply to anyone operating a motor vehicle on a highway in interstate commerce to transportpassengers or property when the vehicle: (1) weighs or has a GVWR of 10,001 pounds or more, (2) is designed or used to transport more than

8 passengers (including the driver) for compensation; or (3) is designed or used to transport more than 15 passengers, including the driver, andis not used to transport passengers for compensation; or (4) is of any size and is used to transport hazardous materials in a quantity requiring

placarding.PLEASE COMPLETE REVERSE SIDE 9653 (Rev. 7/13)

Attach separate sheet if more space is needed

Driving ExperienceIf no driving experience within the last 3 years ~ check here D

CLASS OF EQUIPMENT

Straight Truck

Tractor & Semi-Trailer

Tractor - Two Trailers

Tractor -Three Trailers

(Greater thanMotorcoach - Schooi Bus s passengers)

(Greater thanMotorcoach ~ School BUS 15 passengers)

Other:.

TYPE OF EQUIPMENT(Circle all that apply)

Van, Reefer, Tank. Fiat

Van, Reefer, Tank, Flat

Van, Reefer, Tank, Flat

Van, Reefer, Tank. Flat

N/A

N/A

Van, Reefer, Tank, Fiat, N/A

DATESFROM TO

APPROXIMATENUMBER OF MILES

Accident History (3 years)If no accidents within the last 3 years ~ check here D

DATE(month/year)

NATURE OF ACCIDENT(head-on, rear-end, upset, etc.)

NUMBER OFFATALITIES

NUMBER OFINJURIES

HAZARDOUSMATERIALS SPiLL?

YES ; NO

YES L_ NO

YES : NO

Traffic Convictions and Forfeitures (3 years)If no traffic convictions and/or forfeitures in the last 3 years - check here D

DATE CONVICTED(month/year)

VIOLATfON(Other than violations involving parking only)

STATE OF VIOLATION PENALTY(Forfeited bond, collateral and/or points)

License Information

Section 383.21 FMCSR states "No person who operates a commercial motor vehicle shall at any time have more than onedriver's license".! certify that I do not have more than one motor vehicle license, the information for which is listed below.

State License Number Expiration Date

A. Have you ever been denied a license, permit, or privilege to operate a motor vehicle? H Yes P NoIf yes, give details

B. Has any license, permit, or privilege ever been suspended or revoked? I Yes I NoIf yes, give detaiis

Applicant Certification

This certifies that this application was completed by me, and that all entries on it and information in Et are true and complete tothe best of my knowledge.

Applicant's Signature Date

Copyright 2013 J,J.Ke!ler& Associates, Ine,0 All rights reserved. Neenah.WI • USA'800-327-6868'jjkelier.com* Prinled in IhR Uniteci States 9653 (Rev. 7/13)

ACCIDENT RECORD FOR PAST 3 YEARS OR MORE (ATTACH SHEET IF MORE SPACE IS NEEDED) IF NONE, WRITE NONE

DATES

LAST ACCIDENT

NEXT PREVIOUS

NEXT PREVIOUS

NATURE OF ACCIDENT(HEAD-ON, REAR-END, UPSET, ETC.)

FATALITIES INJURIESHAZARDOUS

MATERIAL SPILL

TRAFFIC CONVICTIONS AND FORFEITURES FOR THE PAST 3 YEARS (OTHER THAN PARKING VIOLATIONS) IF NONE, WRITE NONE

LOCATION DATE CHARGE PENALTY

(ATTACH SHEET IF MORE SPACE IS NEEDED)EXPERIENCE AND QUALIFICATIONS - DRIVER

Driver

licenses or

permits heldin the past3 years

STATE LICENSE NO. CLASS ENDORSEMENTS) EXPIRATION DATE

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

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

[F THE ANSWER TO EITHER A OR B IS YES, GIVE DETAILS

YES

YESNO

NO

DRiVING EXPERIENCE CHECK YES OR NO

CLASS OF EQUIPMENT

STRAIGHT TRUCK _DYES D NOTRACTOR AND SEMi-TRAlLER DYES E_l NO

TRACTOR-TWO TRAILERS DYES D NO

TRACTOR -THREE TRAILERS DYES D NOMore than 8

MOTORCOACH - SCHOOL BUS U YES UNO passengersMore than 15

MOTORCOACH - SCHOOL BUS U YES UNO passengers

OTHER

CIRCLE TYPE OF EQUIPMENT

(VAN, TANK, FLAT, DUMP, REFER)

(VAN. TANK, FLAT, DUMP, REFER)



DATESFROM (M/Y) TO (M/Y)

APPROX.NO.OFMILES(TOTAL)

LIST STATES OPERATED IN FOR LAST FiVE YEARS:

SHOW SPECIAL COURSES OR TRAINING THAT WILL HELP YOU AS A DRIVER;

WHSCH SAFE DRiVING AWARDS DO YOU HOLD AND FROM WHOM?

EXPERIENCE AND QUALIFICATIONS - OTHER

SHOW ANY TRUCKiNG, TRANSPORTATION OR OTHER EXPERIENCE THAT MAY HELP IN YOUR WORK FOR THIS COMPANY

LIST COURSES AND TRAINING OTHER THAN SHOWN ELSEWHERE IN THIS APPLICATION

LIST SPECIAL EQUIPMENT OR TECHNICAL MATERIALS YOU CAN WORK WITH (OTHER THAN THOSE ALREADY SHOWN)

EDUCATIONCIRCLE HIGHEST GRADE COMPLETED: 12345678 HIGH SCHOOL: 1234

LAST SCHOOL AFTENDED (NAME) _(CJTY, STATE)COLLEGE: 1234

TO BE READ AND SIGNED BY APPLICANTThis certifies that this application was completed by me, and that all entries on it and information in it are trueand complete to the best of my knowledge.

Signature:PAGE 4 691 (Rev. 6/13)

Date:

EMPLOYMENT HISTORY (continued)

EMPLOYER DATE

NAME FROMMO. YR.

TOh/10,

ADDRESSPOSITION HELD

CITY STATE ZIPSALARY/WAGE

CONTACT PERSON PHONE NUMBERREASON FOR LEAVING

WERE YOU SUBJECT TO THE FMCSRs+WH!LE EMPLOYED? Q YES D NO

WAS YOUR JOB DESIGNATED AS A SAFETY-SENSITIVE FUNCTION IN ANY DOT-REGULATED MODE SUBJECT TO THE DRUG AND ALCOHOLTESTING REQUIREMENTS OF 49 CFR PART 40? DYES D NO

EMPLOYER DATE

NAME FROMMO,

TOMO.

ADDRESSPOSmON HELD



WERE YOU SUBJECT TO THE FMCSRsf WHILE EMPLOYED? DYES D NO

WAS YOUR JOB DESIGNATED AS A SAFETY-SENSJTIVE FUNCTION IN ANY DOT-REGULATED MODE SUBJECT TO THE DRUG AND ALCOHOLTESTING REQUIREMENTS OF 49 CFR PART 40? DYES D NO

EMPLOYER DATE

NAME FROMMO, YR.

TOMO. YR.




WERE YOU SUBJECT TO THE FMCSRs+WHILE EMPLOYED? DYES D NO


EMPLOYER DATE

NAME FROMMO. YR.

TOMO. YR.

ADDRESSPOSITIOM HELD

CITY STATE ZIPSALARY/WAQE


WERE YOU SUBJECT TO THE FMCSRs+WHILE EMPLOYED? DYES D NO


EMPLOYER DATE

NAME FROMMO. YR.

TOMO. YR.


CITY STATE ZIPSALARY/WAQE


WERE YOU SUBJECT TO THE FMCSRsf WHILE EMPLOYED? DYES D NO

WAS YOUR JOB DESIGNATED AS A SAFETY-SENSiTIVE FUNCTION IN ANY DOT-REGULATED MODE SUBJECT TO THE DRUG AND ALCOHOLTESTING REQUIREMENTS OF 49 CFR PART 40? DYES D NO

includes vehicles having a GVWR of 26,001 !bs. 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 placarding.

fThe Federal Motor Carrier Safety Regulations (FMCSRs) apply to anyone operating a motor vehicle on a highway ininterstate commerce to transport passengers or property when the vehicle: (1) weighs or has a GVWR of 10,001 poundsor more, (2) is designed or used to transport more than 8 passengers (including the driver), OR (3) is of any size and isused to transport hazardous materials in a quantity requiring placarding.

PAGE 3 691 (Rev. 6/13)

REQUEST FOR INFORMATION - From Previous Employer

I hereby authorize you to release the fallowing intormatiou to

for the purposes of investigation as required by Section 391.23 (Prospective Employer)

of the Federal Motor Carrier Safety Regulations


NAME AND ADDRESS OF THIS FORM WAS (ciieck appropriate box)

PREVIOUS EMPLOYER: Q Mailed, Date

Q Faxed, Date

Q Emaiied, Date

[_~] Received by Phone, Date

Name of Person Contacted

Name of Applicant:

Social Security No.; ,^_^^^^ ^_ Date of Birth:

DcarSir/itvtadam:

Die above named individual has made application to this company for a position as

and states that hc/slie was employed by you as

from (ni/y) _ to (m/y)In accordance witli Section 391.23, we are obligated to request the information below from all previous employers of the

applicant that employed him/her to operate a commercial motor vehicle witfiin the 3 years preceding (date ofappiication)

Please complete die infonnation below and return to us within 30 days, as required by Section 39L23(g). You may return She information by

telephone, fax, mail, or email.

Prospective Employer: _ Attention:Street: City, State, Zip;

Telephone; Fax: .....___ Email:

TO BE COMPLETED BY PREVIOUS EMPLOYER

SECTION 1: DRIVER IDENTIFICATION

The applicant named above was employed by us. Yes |_| No

Employed as . __ from (m/y) _ to Qri/y)

If driver was involved in a safety-sensitive position subject to drug and alcohol testing under Part 40, check here | | .

SECTION 2: SAFETY PERFORMANCE HISTORYI. Did he/she drive motor vehicles for you? Yes |_| No |_| If yes, what type? Straight Truck || Tractor-Seniiti-aiier |_| Bus

Cargo Tank Q DoubIes/Triples [_] Oiiier (Specify)

2. Reason for leaving your employ: Discharged Resignation Lay OfT [ Military Duty

If there is no safety performance history to report, check here | |, sign below and return.

ACCIDENTS: Complete the following for any accidents inciuded on your accident register (§390.15(b)) that involved the applicant in the 3

years prior to the application date shown above, or check here |_| if there is no accident regisler data for this driver.

Date Location No. of Injuries No.ofFataiities Hazmat Spill

1.

2.

3.

Please provide information concerning any other accidents involving the applicant that were reported to government agencies or insurefs or

retained under internal company policies:

Any other remarks;

Signature:

Titic: ^ Date:

PREVIOUS EMPLOYER; KEEPA RECORD OF 'HHS REQUEST AND THE RESPONSE FOR ONE YEAR,INCLUDING THE DATE, THE PARTY TO WHOM IT WAS RELEASED, AND A SUMMARY 11JLNTIFY1NG WHAT WAS PROVIDED.

©Copyright 2004 JJ.KKLI.HR&ASSOaATES, INC., Neenah,W! 17-F 762(600)327-6868 - www.JIKeHer.com • Prinled in the United States (REV. 7/04}

PREVIOUS EMPLOYER ALCOHOL & DRUG TEST INFORMATION

SECTION 1: TO BE COMPLETED BY PROSPECTIVE EMPLOYEE

I, (Print Name)

First, M.l., Last Soda! Security Number

hereby authorize:Date of Birth

Previous Employer: .._....._._.....___ Email:

Street: Telephone:

City, State, Zip: ...._.__ Fax No.:

to release and forward the information requested by section 2 (below) of this document concerning my Alcohol and Conlrolied

Substances Testing records within the previous 3 years from _^.(date of employment application)

To:

Prospective Employer:

Attention: Telephone:

Street:

City, State, Zip:

in compliance with §40.25(g) and 391 -23(h), release of this information must be made in a written form that ensures confidentiality, such

as fax, email, or letter. Under §391.23(g), you must respond to this inquiry within 30 days of receipt.

Prospective employer's confidential fax number:

Prospective employer's confidential e-mail address:


This information is being requested in compliance with §40.25 and §391.23. (See back of form for regulations.)

SECTION 2: TO BE COMPLETED BY PREVIOUS / CURRENT EMPLOYER

If applicant was not subject to Department of Transportation testing requirements while employed by you, please check here D ,fill in the

dates of employment from . to ,___ .complete bottom of Section 2, sign, and return.

Applicant was subject to Department of Transportation testing requirements from , to

In answering these questions, include any required DOT drug or aicohol testing information you obtained from other employers in the 3 years prior to the

appiicatson date shown in Section 1.

Within the past 3 years from the application date shown in Section 1: YES NO

1 .Has this person violated any of the drug and/or alcohol prohibitions under 49 CFR Part 40 or Subpart B of Part 382, inciuding | |• An alcohol test with a result of 0.04 or higher aicohoi concentration.

• A controlled substances test result of positive, adulterated, or substituted.

• A refusal to submit to a random, post-accident, reasonable-suspicion, or follow-up controlled substances or alcoho! test.

• Alcohol use white performing or within 4 hours before performing safety-sensitive functions.

• Alcohol use after an accident, En violation of §382.303.

• Controlled substances use while on duty, except as allowed under §382.213,

2. If this person violated a DOT drug and/or alcohol prohibition, did he/she fail to begin or complete a rehabilitation N/A

program prescribed by a Substance Abuse Professional (SAP)? If rehabilitation was required but you do not know if

he/she beaan or comoieted such a Droaram. check here D

3. If this person successfully completed a SAP'S rehabilitation referral and remained in your employ, did he/she

subsequently have an aScoho! test result of 0.04 or greater, a verified positive drug test, or refusal to be tested?Name:

Company:

Street:

City, State, Zip: Telephone:

Section 2 Completed by (Signature): _ ,,^ Date:

SECTION 3: TO BE COMPLETED BY PROSPECTIVE EMPLOYERThis form was (check one) | | Faxed to previous employer | | Mailed | | Emailed | | Other

Complete beiow when information is obtained, ^ate

Information received from:

Recorded by; _ Method: DFax D Mail D Email Q Telephone

Date: —.— II OtherCopyright 20-13 J. J. Keller & Associates, lnc.®A)l rights reserved. 6828

Neenah, WI-USA-800-327-6868.jjkelSer.com'Printed in the United States (Rev. 7/13)

Motor Vehicle Driver's

CERTIFICATION OF COMPLIANCEWITH DRIVER LICENSE REQUIREMENTS

MOTOR CARRIER INSTRUCTIONS: The requirements in Part 383 apply to every driver whooperates En intrastate, interstate, or foreign commerce and operates a vehicle weighing

26,001 pounds or more, can transport more than 15 people, or transports hazardous

materials that require placarding.

The requirements in Part 391 apply to every driver who operates in interstate commerce and

operates a vehicle weighing 10,001 pounds or more, can transport more than 15 peopie, or

transports hazardous materials that require placarding.

DRIVER REQUIREMENTS: Parts 383 and 391 of the Federal Motor Carrier SafetyRegulations contain certain driver licensing requirements that you as a driver must compiy

with, including the following:

1} POSSESS ONLY ONE LICENSE: You, as a commerical vehicle driver, may notpossess more than one motor vehicle operator's license.

2) NOTIFICATION OF LICENSE SUSPENSION, REVOCATION OR CANCELLATION:Sections 391.15(b)(2) and 383.33 of the Federal Motor Carrier Safety Reguiationsrequire that you notify your employer the NEXT BUSINESS DAY of anyrevocation or suspension of your driver's license. In addition, Section 383.31

requires that any time you vioiate a state or local traffic law (other than parking),you must report it within 30 days to: 1} your empioying motor carrier, and 2) thestate that issued your license (If the violation occurs En a state other than the one

which issued your license). The notification to both the employer and the state must

be in writing.

3) CDL DOMICILE REQUIREMENT: Section 383.23(a)(2) requires that yourcommercial driver's license be issued by your legal state of domiciie, where you

have your true, fixed, and permanent home and principal residence and to which

you have the intention of returning whenever you are absent. If you establish a

new domicile in another state, you must apply to transfer your CDL within 30

days.

The foilowing license is the only one I will possess:

Driver's License No. _ State _ Exp. DateDRiVER CERTIFICATION: f certify that i have read and understood the above requirements.

Driver's Name (Printed):

Driver's Signature: _ DateNotes:

(This (arm is not required for DOT compliance)

90-F1617© Copyright 2008 J.J. KELLER & ASSOOATRS. INC., Neenah. Wl • USA • (800) 327-6868 • VAtnu.JjkQller.com • Printed in the United Stales (REV. 3/08)

Company Name

FAIR CREDIT REPORTING ACT DISCLOSURE STATEMENT

In accordance with the provisions of Section 604(b)(2)(A) of the Fair Credit Reporting Act,Public Law 91-508, as amended by the Consumer Credit Reporting Act of 1996 (Title II,Subtitle D, Chapter I, of Public Law 104-208), you are being informed that reports verifyingyour previous employment, previous drug and alcohol test results, and your driving record maybe obtained on you for employment purposes. These reports are required by Sections 382.413,391.23, and 391.25 of the Federal Motor Carrier Safety Regulations.


Print name Social Security number

1I6-FS-C2©Copyright 1999 J.J. KELLER & ASSOCIATES, INC., Heenah. Wl - USA - (800)327-6868 - Printed in Ihe United States (REV. 7/98)

REQUEST FOR CHECK OF DRIVING RECORDNOTE: This form may only be used in states that do not require a specific form.

CAUTION: When using a third party to request background information on applicants or existing employees - such as motor

vehicle records, information from previous employers, criminal records, or credit history - you are subject to the Fair Credit

Reporting Act (FCRA) and State consumer reporting laws. Under FCRA, the third-party vendor is considered a consumer reporting

agency (CRA) and the employee background information is a consumer report. Before you can obtain a consumer report from a

CRA, you must provide applicants and employees with a disclosure stating that your company may obtain such a report for

employment purposes, and you must have authorization from the appiicant or employee to conduct the check. You must also

provide a copy of the Federal Trade Commission's notice called "A Summary of Your Rights Under the Fair Credit Reporting Act."The notice, disclosure, and authorization are not included En this file, and some state laws have additional requirements. Consult

with your CRA on the need and use of such documents.

] hereby authorize you to release the foliowing information to

(Empioyer)

for purposes of investiqation as reauired by Sections 391.23 and 391.25 of the Federal Motor Carrier Safety RenulatEons. You

are released from any and a!i liability which may result from furnishing such information.

(Driver's Signature)

i also hereby certify that this report request and thestate motor vehicle records under the provisions of the

Section 300002(a)).

(Signature of Requester)

above driver's release notice

Driver's Privacy Protection

meet

Act of

the definition1994 (Public

of "

Law

(Date)

'permissible uses" of

103-322, Title XXX,

(Date)

TO:

DEAR SIR/MADAM:

The following named person has made application with our company for the position of

. In accordance with Section 391.23, Federal Department of Transportation Regulations,

please furnish the undersigned with the applicant's driving record for the past three years.

The following named person is employed with our company in the position of

. In accordance with Section 391.25, Federai Department of Transportation Regulations,

please furnish the undersigned wiEh the employee's driving record for the past year.

NAME OF DRIVER:

ADDRESS:(Number & Street)

FORMER ADDRESS:(Number & Street)

DATE OF BIRTH: SSN

REQUESTED BY

(Name of Company)

(Address)

(City)

(City)

LICENSE NO.

(Typed Name)

(Title)

(State)

(State)

(ZEpcode)

(Zipcode)

(City) (State) (Signature)

Copyright 2015 J. J. Kelki & Associate, Inc. * Neenah, W! • JJKelttir.com * (800) 327-6868 • Piinted in the USA 732 (Rev. 10/15)

PREVIOUS PRE-EMPLOYMENT EMPLOYEEALCOHOL AND DRUG TEST STATEMENT

Sec. 40.25(j) As the employer, you must also ask the employee whether he or she has tested positive, or refused to

test. on any pre-empioyment drug or alcohoi test administered by an employer to which the employee applied for, butdid not obtain, safety-sensitjve transportation work covered by DOT agency drug and alcohol testing rules during the

past two years. If the employee admits that he or she had a positive test or a refusal to test, you must not use the

employee to perform safety-sensitive functions for you, until and unless the employee documents successful

completion of the retLirn-to-duty process, (see Sec. 40.25(b)(5) and (e))

Prospective Employee Name: ID Number:

(print)

The prospective employee is required by Sec. 40.25(j) to respond to the following questions.

1) Have you tested positive, or refused to test, on any pre-employment drug or alcohol test

administered by an employer to which you applied for, but did not obtain, safety-

sensitive transportation work covered by DOT agency drug and alcohol testing rules

during the past two years?

Check one: D Yes Q No

2} If you answered yes, can you provide/obtain proof that you've successfully completed the DOT

return-to-duty requirements?

Check one: D Yes Q No

certify that the information provided on this document is true and correct.

Prospective Employee Signature: Date:

Witnessed By: Date:(signature)

^uSeTbyJJ KELLER & ASSOCIATES, INC. ORIGINAL - EMPLOYER 886-FS-C2 6801NEENAH,Wi 54957-0368 (Rev. 7/03)1-800-327-6868 - www.ijke11er.com

THE BELOW DISCLOSURE AND AUTHORIZATION LANGUAGE IS FOR MANDATORY USE B^ ALLACCOUNT HOLDERS

IMPORTANT DISCLOSURE

REGARDING BACKGROUND REPORTS FROM THE PSP Online Service

In connection with your application for employment with _("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 fromFMCSAin 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 ReportingAct before taking any final adverse action. If any final adverse action is taken against you based upon your driving history or safetyreport, the Prospective Employer will notify you that the action has been taken and that the action was based in part or in whole on thisreport.

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 fi'om FMCSA; the name, address, and

the toll free telephone number ofFMCSA; that the FMCSA did not make the decision to take the adverse action and is unable to provideyou 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 crasheswere 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 Safely Regulations (FMCSR) violations that have been adjudicated by a court of lawwill 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 __ ("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 tlu-ce (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.dotgov. 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 wiiich 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-dnver 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 Ihat 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 Isign 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.

Date:

Signature

Name (Please Print)

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 writtenor 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.

LAST UPDATED !2/22/20!5

Employment Eligibility Verification

Department of Homeland Security

U.S. Citizenship and Immigration Services

USCISForm 1-9

0MB No, 1615-0047

Bxpn-cs 08/31/2019

^-START HERE: Read instructions carefully before completing this form. The instructions must be avaHable, either in paper or electronically,

during completion of this form. Employers are liable for errors in the completion of this form.

ANTI-DISCRIMINATION NOTICE: It is illegal to discriminate against work-authorized individuals. Employers CANNOT specify whichdocument(s) an employee may present to establish employment authorization and identity. The refusal to hire or continue to employan individual because the documentation presented has a future expiration date may also constitute illegal discrimination.

Seic?6ion;ÊniRipye^tliSnW^firs^Say^'empfp^ ''-'• ' .;:'<:-' .:/''y^^:~

Last Name (Family Name) First Name (Given Name)

Address (Street Number and Name)

Date of Birth (mm/dd/yyyy)

\pt. Number

f.S, Social Security Number

Middle Initial Other Last Names Used (if any)

City or Town

Employee's E-mail Address

State

Employee's I

ZIP Code

elephone Number

I am aware that federal law provides for imprisonment and/or fines for false statements or use of false documents in

connection with the completion of this form.

I attest, under penalty of perjury, that I am (check one of the following boxes):

1. A citizen of the United States

2. A noncitizen national of the United States (See instructions)

3. A lawful permanent resident (Alien Registration Number/USCIS Number):

j[ 4. An alien authorized to work untii (expiration date, if applicable, mm/dd/yyyy):

Some aliens may wriie "N/A" in the expiration date Held. (See instructions)

Aliens authorized to work must provide only one of the following document numbers to complete Form 1-9:An Alien Registration NumberAJSCtS Number OR Form 1-94 Admission Number OR Foreign Passport Number.

1. Alien Registration Number/USCiS Number:

OR2. Form 1-94 Admission Number:

OR3. Foreign Passport Number:

Country of Issuance:

QR Code - Section 1Do Not Wriie In This Space

Signature of Employee Today's Date (mm/dd/yyyy)

Pr^p3reranôi^Trari«iato^C^rtiti (ch eck Q n e):Ql^Jc|rii3t usâ;^re^^<3r]T£»Ts[a^ 'Q^|3repar^s}!anci/or lTanstatCff(5);ass^|t^.tti^@mploy@^

(F^lds:.l)ôw:jmiiêpQnipfÎ attest, under penalty of perjury, that I have assisted in the completion of Section 1 of this form and that to the best of myknowledge the information is true and correct.

Signature of Preparer or Translator Today's Date (mm/dd/yyyy)

Last Name (Family Name)

Address (Street Number and Name)

First Name (Given Name)

City or Town State ZIP Code

SS) 1::: Employer Completes Next Page

Form 1-9 07/17/17 N Page 1 of 3

street address city state zip - whimsytrucking.com · [f the answer to either a or b is yes, give...

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