The purpose of this application is the determination of the applicant’s qualifications to operate Motor Carrier equipment in accordance with the requirements of the Federal Motor Carrier Safety Regulations, Green Lines Transportation, Inc. and Roger Bettis Trucking, Inc. Applicants are considered without regard to an individual’s race, religion, color, gender, sexual orientation, gender identity, marital status, age, physical disability, genetic information, or national origin.
INSTRUCTIONS TO APPLICANT: PLEASE ANSWER ALL QUESTIONS. IF THE ANSWER TO ANY QUESTION IS ‘NO’ OR ‘NONE’ DO NOT LEAVE THE ITEM BLANK, BUT WRITE ‘NO’ OR ‘NONE’. USE ALL CAPITAL LETTERS.
Past 10 Years
Begin with your present or most recent job and work backward, listing your employers for at least 10 years, including all full and part-time employment. If military service is listed, please include a copy of your DD214 and/or DD348. Please list all unemployment dates in section on the next page. ALL TIME MUST BE ACCOUNTED FOR, INCLUDING MILITARY SERVICE, SELF-EMPLOYMENT AND PERIODS OF UNEMPLOYMENT. IT IS ACCEPTABLE TO BE SLIGHTLY OFF ON DATES OF EMPLOYMENT, DATES THAT ARE 4 OR MORE MONTHS OFF ARE NOT ACCEPTABLE. If you were employed by or are an Owner/Operator please list who the truck was leased to. Use a supplementary sheet if necessary.
List all driver licences/permits held the past ten (10) years
List all car, truck, ect. Moving traffic convictions and suspensions for the past (5) years (if none, write none)
FEDERAL MOTOR CARRIER SAFETY REGULATIONS SECTION 391.41 PROVIDES THAT A PERSON SHALL NOT OPERATE A MOTOR VEHICLE UNLESS THAT PERSON IS PHYSICALLY QUALIFIED TO DO SO. IT IS AN ESSENTIAL FUNCTION OF AN OVER-THE-ROAD DRIVER TO SATISFY THE DOT QUALIFICATIONS.
Please answer YES or NO to the following questions:
Below is a list of questions that will be asked on the mandatory Department of Transportation Physical
*Applicant agrees and understands that the completion of this application does not constitute authorization for the applicant to drive, nor does it obligate in any way Green Lines Transportation, Inc. to authorize the applicant to drive.
*Authorizes Green Lines Transportation, Inc. to obtain consumer reports to prepare an investigative consumer report. The investigative consumer report may consist of contacting all listed prior employers to verify your employment history. It may also include, but not limited to, credit information reports, criminal history reports, and driving history record. Under the provisions of the Fair Credit Reporting Act (15 USC at 1681-1681u) as amended, before we can seek such reports, we must have your written permission to obtain the information. You have the right, upon written request, to a complete and accurate disclosure of the nature and scope of the investigation. You are also entitled to a copy of your Rights Under the Fair Credit Reporting Act.
* Authorize Green Lines Transportation, Inc. and its subsidiaries, affiliates or its agent to request driver information records relating to your previous driver employment, including but not limited to, previous driver employment history, names and dates of previous employers, reason for termination of employment, work experience, accidents, Motor Vehicle Record request, Alcohol and Drug Test results, Criminal History and Insurance Claim Reports. I further understand that such information will include information from various state and local agencies which maintain records concerning traffic offenses, accidents, etc. (Applicant have the right to review information obtained, to correct errors in that information, and rebut perceived incorrect information.)
*Understand and agree that I will be required to submit to and pass a drug test and various other tests as required as a condition of pre-employment, and thereafter in accordance with Green Lines Transportation, Inc. policies and procedures and federal regulations.
*Agree that providing false, misleading or incomplete statements in this application and/or supplemental documents in connection with employer’s evaluation of me as a candidate for employment is ground for immediate termination of my employment, regardless of when such information is discovered.
*Certify 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.
In connection with your application for employment with GREEN LINES TRANSPORTATION, INC. AND ROGER BETTIS TRUCKING, INC. 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; thatthe 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 ofthe 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 Data Q 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 orwithout 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 GREEN LINES TRANSPORTATION, INC. AND ROGER BETTIS TRUCKING, INC. 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 andinspection 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. l 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 DataQ/; 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.
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 inwhole, exactly asprovided. 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 49C.F.R.383.5. LAST UPDATED 12/22/2015
In conjunction with my application for employment (including contract services) with you, my prospective employer, I understand that you intend to hire Selection.com to obtain Consumer Reports and/or Investigative Consumer Reports (hereinafter called ‘Reports’) about me as defined in the Fair Credit Reporting Act (FCRA). These ‘Reports’ may include information concerning my credit worthiness, credit standing, credit capacity, character, academic background, credentials, work habits, work performance, work experience, reasons for work termination, general reputation, personal characteristics or mode of living. You also may seek information concerning my employment history, workers’ compensation history, motor vehicle record, education background, civil litigation history and/or criminal record.
I understand that you may rely on any or all of the above referenced information in determining whether to extend an offer of employment to me. If you contemplate making and adverse employment-related decision that will affect me based, in whole or in part, upon a ‘Report’ obtained from Selection.com, I will be provided with a copy of the ‘Report’ and a written summary of my consumer Rights under the FCRA before you finalize that decision.
I have read the above disclosure and I hereby authorize you, Selcetion.com or its authorized agents to obtain the above referenced information about me. I also authorize all agencies, bureaus, employers, information service organizations and individuals to provide any of the above referenced knowledge or information they have concerning me. If I am hired, this authorization shall remain on file and shall serve as an ongoing authorization for you to obtain ‘Reports’ about me from Selection.com at any time during my employment with you. A photocopy or facsimile of this authorization shall be as valid as the original. I agree that any and all disputes arising from this ‘Report’ shall be brought only in state or federal court in the State of Ohio and shall be governed by, and construed in accordance with, the laws of the State of Ohio.
THE FOLLOWING INFORMATION IS REQUIRED TO CONDUCT THE BACKGROUND INVESTIGATION
List states and counties of residence, other then above, for the past (7) years:
My prospective employer understands age to be a protected characteristic and the information requested will not be used as the basis for any employment decision.
Notice to Applicants Living in CA, OK or MN
** By entering my email address, I authorize Selection.com to deliver my Report via email
Notice to California Residents
Under section 1786.22 of the California Civil Code, you may view the file maintained on you by Selection.com during normal business hours. You may also obtain a copy of this file, either in person or by mail, by submitting proper identification and paying the costs of duplication services. You may also receive a summary of the file by telephone be being able to provide adequate identification as to allow Selection.com to determine with reasonable certainty that you are the subject of the report. Selection.com is required to have personnel available to explain your file to you and must explain to you any coded information appearing in your file. If you appear in person, another person of your choice may accompany you, providing that this additional person furnishes proper identification.
If Faxing or emailing request, this section must be completed by employer for processing
Selection.com 155 Tri County Boulevard; Suite 150 Cincinnati, OH 45246 Telephone – 800.325.3609 Fax – 888.767.2435
For background check entry, send to email@example.com
For employment or education verification purposes, email to firstname.lastname@example.org with the applicant’s full name in the subject line.
DOT D/A Disclosure and Authorization
Send to Fax# (800) 257-8069
Company Name: Green Lines Transportation, Inc.
Company Contact Name: Stephen Ryan
Fax #: 330.863.1558
HireRight Account Code: CVFGE
PART I - DISCLOSURE AND AUTHORIZATION FOR RELEASE OF INFORMATION FOR EMPLOYMENT PURPOSES - 49 CFR PART 391.23, DOT DRUG AND ALCOHOL TESTING
In accordance with DOT Regulation 49 CFR Part 391.23, I hereby authorize release of my DOT-regulated drug and alcohol testing records by the DOT-regulated employer(s) listed below to HireRight for the purpose of HireRight transmitting such records to the HireRight customer listed above. I understand that information/documents released pursuant to this Part I is limited to the following DOT-regulated testing items, including pre-employment testing results, occurring during the previous three (3) years: (i) alcohol tests with a result of 0.04 or higher: (ii) verified positive drug tests; (iii) refusals to be tested(including adulterated and/ or substituted tests): (iv) other violations of DOT drug and alcohol testing regulations(i.e., violations of 49 CFR Subpart B); (v) information obtained from previous employers of a drug and alcohol rule violation; and (iv) any documentation of completion of the return-to-duty process following a rule violation.
If any company listed below furnishes HireRight with information concerning items (i) through (iv) above, I also authorize such company to furnish the following information to HireRight, if applicable: (i) dates of my negative drug and/or alcohol tests and/or tests with results below 0.04 during the previous three (3) years; and (ii) the name and phone number of any substance abuse professional who evaluated me during the previous three (3) years.
List a II DOT-regulated employers you have applied with and/or worked for in a safety-sensitive function during the previous three (3) years. If necessary, attach additional pages, including the date, your name, social security number and signature.
By signing below, I certify that: (i) all information provided herein is complete and accurate; (ii) I have read and fully understand this Part I disclosure and authorization for release as well as the attached FMCSA Notification of Driver Rights and any applicable state law notices; (i ii) prior to signing I was given an oppurtunity to ask quesions and to have those questions answered to my satisfaction; (iv) I execute this authorization voluntarily and with the knowledge that the information obtained pursuant to this authorization could affect my eligibility for employment, promotion, retention or other lawful purposel (v) I understand I may review this document with legal counsel prior to signing; and (vI) facsimile or photographic copies of this authorization are as valid as an original.
FORM OF CONSENT OF COMMERCIAL DRIVER
A commercial driver may provide consent to the submission of a CDLIS Inquiry by the following Instrument of Written Consent for CDLIS Inquiry or by a general form of consent that includes an expression of consent that is substantially equivalent.
INSTRUMENT OF WRITTEN CONSENT FOR CDLIS INQUIRY
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