Click here to download the Application in PDF form. Application Green Lines Application for Employement Step 1 of 10 - I. GENERAL 10% 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.Date*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Check One:* Owner/Operator Company Full Name:* Home Phone:* Current Address* City* State* Zip* Past 10 YearsOther Address #1 City State Zip Other Address #2 City State Zip Other Address #3 City State Zip Are you legally authorized to be employed in the United States? Yes No Personal InformationDate of Birth:*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920DOT Physical Expiration Date:* Social Security Number:* Email Address Driver's License #:* Federal I.D. No: IN CASE OF AN EMERGENCY NOTIFY:* City* State:* Phone* Relationship:* How did you hear about Green Lines Transportation, Inc?* Do you have friends or relatives employed with us? Yes No Name/Relationship: Have you worked here before?* Yes No Date from:*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Date to:*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Reason for leaving?* Select highest grade completedGrade School* 1 2 3 4 5 6 7 8 High School:* 1 2 3 4 College: 1 2 3 4 Last public school attended:* Did you graduate?* Yes No Do you have your GED?* Yes No City:* State* List any special courses that might help you in the position being applied for: Driving School: City State MilitaryBranch: From:Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920To:Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920DD214 Narrative reason for discharge: Honorable discharge? Yes No 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.CURRENT - MOST RECENT EMPLOYERName: Address City: State: Zip: Telephone: Was this position considered saftey sensative and subject to DOT Drug & Alcohol Testing? Yes No Please explain any accidents:Reason for Leaving:Position: Company Driver Owner/Operator Are you presently employed? Yes No *May we contact your current employer? Yes No Did you drive a tractor trailer full time at this job? Yes No Position Held: From:Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920To:Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Rate of Pay: Supervisor: Were you subject to Federal Motor Carrier Safety Regulations Yes No Number of States driven in? Number of accidents? MOST RECENT EMPLOYER #2Name: Address City: State: Zip: Telephone: Was this position considered saftey sensative and subject to DOT Drug & Alcohol Testing? Yes No Please explain any accidents:Reason for Leaving:Position: Company Driver Owner/Operator Are you presently employed? Yes No Did you drive a tractor trailer full time at this job? Yes No Position Held: From:Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920To:Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Rate of Pay: Supervisor: Were you subject to Federal Motor Carrier Safety Regulations Yes No Number of States driven in? Number of accidents? MOST RECENT EMPLOYER #3Name: Address City: State: Zip: Telephone: Was this position considered saftey sensative and subject to DOT Drug & Alcohol Testing? Yes No Please explain any accidents:Reason for Leaving:Position: Company Driver Owner/Operator Are you presently employed? Yes No Did you drive a tractor trailer full time at this job? Yes No Position Held: From:Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920To:Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Rate of Pay: Supervisor: Were you subject to Federal Motor Carrier Safety Regulations Yes No Number of States driven in? Number of accidents? MOST RECENT EMPLOYER #4Name: Address City: State: Zip: Telephone: Was this position considered saftey sensative and subject to DOT Drug & Alcohol Testing? Yes No Please explain any accidents:Reason for Leaving:Position: Company Driver Owner/Operator Are you presently employed? Yes No Did you drive a tractor trailer full time at this job? Yes No Position Held: From:Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920To:Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Rate of Pay: Supervisor: Were you subject to Federal Motor Carrier Safety Regulations Yes No Number of States driven in? Number of accidents? MOST RECENT EMPLOYER #5Name: Address City: State: Zip: Telephone: Was this position considered saftey sensative and subject to DOT Drug & Alcohol Testing? Yes No Please explain any accidents:Reason for Leaving:Position: Company Driver Owner/Operator Are you presently employed? Yes No Did you drive a tractor trailer full time at this job? Yes No Position Held: From:Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920To:Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Rate of Pay: Supervisor: Were you subject to Federal Motor Carrier Safety Regulations Yes No Number of States driven in? Number of accidents? MOST RECENT EMPLOYER #6Name: Address City: State: Zip: Telephone: Was this position considered saftey sensative and subject to DOT Drug & Alcohol Testing? Yes No Please explain any accidents:Reason for Leaving:Position: Company Driver Owner/Operator Are you presently employed? Yes No Did you drive a tractor trailer full time at this job? Yes No Position Held: From:Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920To:Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Rate of Pay: Supervisor: Were you subject to Federal Motor Carrier Safety Regulations Yes No Number of States driven in? Number of accidents? MOST RECENT EMPLOYER #7Name: Address City: State: Zip: Telephone: Was this position considered saftey sensative and subject to DOT Drug & Alcohol Testing? Yes No Please explain any accidents:Reason for Leaving:Position: Company Driver Owner/Operator Are you presently employed? Yes No Did you drive a tractor trailer full time at this job? Yes No Position Held: From:Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920To:Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Rate of Pay: Supervisor: Were you subject to Federal Motor Carrier Safety Regulations Yes No Number of States driven in? Number of accidents? MOST RECENT EMPLOYER #8Name: Address City: State: Zip: Telephone: Was this position considered saftey sensative and subject to DOT Drug & Alcohol Testing? Yes No Please explain any accidents:Reason for Leaving:Position: Company Driver Owner/Operator Are you presently employed? Yes No Did you drive a tractor trailer full time at this job? Yes No Position Held: From:Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920To:Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Rate of Pay: Supervisor: Were you subject to Federal Motor Carrier Safety Regulations Yes No Number of States driven in? Number of accidents? MOST RECENT EMPLOYER #9Name: Address City: State: Zip: Telephone: Was this position considered saftey sensative and subject to DOT Drug & Alcohol Testing? Yes No Please explain any accidents:Reason for Leaving:Position: Company Driver Owner/Operator Are you presently employed? Yes No Did you drive a tractor trailer full time at this job? Yes No Position Held: From:Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920To:Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Rate of Pay: Supervisor: Were you subject to Federal Motor Carrier Safety Regulations Yes No Number of States driven in? Number of accidents? MOST RECENT EMPLOYER #10Name: Address City: State: Zip: Telephone: Was this position considered saftey sensative and subject to DOT Drug & Alcohol Testing? Yes No Please explain any accidents:Reason for Leaving:Position: Company Driver Owner/Operator Are you presently employed? Yes No Did you drive a tractor trailer full time at this job? Yes No Position Held: From:Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920To:Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Rate of Pay: Supervisor: Were you subject to Federal Motor Carrier Safety Regulations Yes No Number of States driven in? Number of accidents? Unemployment DatesFrom:Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920To:Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Did you receive unemployment benefits Yes No LicenseList all driver licences/permits held the past ten (10) yearsState: License Number: Type & Endorsements: Expiration Date: State: License Number: Expiration Date: Type & Endorsements: State: License Number: Type & Endorsements: Expiration Date: Traffic Convictions/SuspensionsList all car, truck, ect. Moving traffic convictions and suspensions for the past (5) years (if none, write none)DateMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Location (State): If speeding MPH over limit: Charge: Penalty: DateMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Location (State): If speeding MPH over limit: Charge: Penalty: Accident RecordDate:Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Vehicle Type: Nature of Accident(Head on, Rear End, Upset, Ect.): Preventable or Non-preventable: Towable: Yes No Fatalities: Yes No Injuries: Yes No Amount of property damage: Nature and Extent of ExperienceType: From: MM slash DD slash YYYY To: MM slash DD slash YYYY Trailer Length: Approx # of miles: States Operated: A. Has any license, permit or privilege ever been revoked or suspended? Yes No B. Have you ever been arrested and/or convicted for driving under the influence of alcohol or drugs or have a current charge pending? Yes No C. Have you ever been convicted for possession, sale, or use of a narcotic drug, amphetamine, or derivative thereof, or have a current charge pending? Yes No D. Have you ever been convicted of a felony and/or misdemeanor? Yes No E. Have you tested positive for controlled substance in the last 3 years? Yes No F. Have you had a breath alcohol test with concentration of .04 or greater in the last 3 years? Yes No G. Have you refused a DOT required test for drugs or alcohol in the last 3 years? Yes No H. have you ever tested positive for a DOT pre-employment drug test? Yes No If the answer to any of the above is 'Yes', provide the name, address and phone number for the Motor Carrier: Address: City: State: Zip: Phone If the answer to any of the above is 'Yes', provide the name, address and phone number for the Motor Carrier: Address: City: State: Zip: Phone Physical HistoryFEDERAL 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 Examination Form.Heart:* Yes No Date: MM slash DD slash YYYY High Blood Pressure:* Yes No Date: MM slash DD slash YYYY Hernia:* Yes No Date: MM slash DD slash YYYY Cardiovascular Disease:* Yes No Date: MM slash DD slash YYYY Physical Disorders:* Yes No Date: MM slash DD slash YYYY Diabetes:* Yes No Date: MM slash DD slash YYYY Seizures:* Yes No Date: MM slash DD slash YYYY Any other Nervous Disorders:* Yes No Date: MM slash DD slash YYYY Convulsions/Fainting:* Yes No Date: MM slash DD slash YYYY If the answer to any of the above questions was 'YES', please explain in detail:Vision - Do you have at least 20/40 (Snellen) with or without corrective lenses in both eyes?* Yes No List all medications being taken:Do you use, or have you every used, amphetamines, narcotics, marijuana, or any other habit-forming drug or controlled substance?* Yes No If 'Yes', when?* Time lost from work in the past three years:* Can you perform the following essential job functions with or without reasonable accommodation?Pull 5th wheel pin with an average of 200 lbs. force?* Yes No List removable sides weighing approx. 35 lbs.?* Yes No Pull yourself into a tractor at 60% of your body weight??* Yes No Lift 100 lbs. tarps over your head?* Yes No AuthorizationBy completing and submitting this application, I,* *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.) This includes requesting MVR's from any state or country jurisdiction for the duration of employment for the purpose of the annual violations review (§391.23). *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. Digital Signature*Date* MM slash DD slash YYYY IMPORTANT DISCLOSURE REGARDING BACKGROUND REPORTS FROM THE PSP ONLINE SERVICE 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. Date:* MM slash DD slash YYYY Digital Signature:*Name (print):* 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 EMPLOYMENT INQUIRY RELEASE 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. Digital Signature:*Date: MM slash DD slash YYYY THE FOLLOWING INFORMATION IS REQUIRED TO CONDUCT THE BACKGROUND INVESTIGATION Print Name:* Social Security Number:* Previous or Maiden name (if applicable):* Phone Number:* Street Address:* City:* State:* Zip:* Driver's License Number:* State Issued:* Email Address: List states and counties of residence, other then above, for the past (7) years: County: State: County: State: County: State: County: State: County: State: County: State: County: State: County: State: County: State: FOR IDENTIFICATION PURPOSES ONLY: DATE OF BIRTH:* MM slash DD slash YYYY 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 checking this box, I request to receive a free copy of any Report ordered on me. Email Address: ** 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 processingCustomer Number: Location or Store Number: Date Submitted: Contact Person: Phone Number: Position Applied For: Information Requested:Combined Report: Individual Reports: Criminal Convictions: Yes No County(s) and State(s): Other: 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 requests@selection.com For employment or education verification purposes, email to releases@selection.com with the applicant’s full name in the subject line. TRUCKING INDUSTRY: DOT D/A Disclosure and Authorization Send to Fax# (800) 257-8069 HireRight Customer: 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. Previous DOT-Regulated Employer: City: State: PhonePrevious DOT-Regulated Employer: City: State: PhonePrevious DOT-Regulated Employer: City: State: PhonePrevious DOT-Regulated Employer: City: State: PhonePrevious DOT-Regulated Employer: City: State: PhonePrevious DOT-Regulated Employer: City: State: Phone 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. Print Applicant Name:* Social Security #:* Digital Signature:*Date* MM slash DD slash YYYY ATTACHMENT A 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 I, the undersigned commercial driver, hereby authorize Green Lines Transportation, Inc. to request or access data pertaining to me within the CDLIS Central Site, to obtain all CDLIS Master Pointer Record data relating to me (CDLIS Data), and to request and obtain my driver record from the jurisdiction identified in the CDLIS Data in accordance with applicable state law and the Driver Privacy Protection Act. I hereby further authorize the disclosure of my CDLIS Data and driver records to Green Lines Transportation, Inc.I hereby give this consent on this date selected.* MM slash DD slash YYYY COMMERCIAL DRIVER (SIGNATURE)*PRINT NAME (FIRST, LAST)*
Green Lines Application for Employement
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 Examination Form.
*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.) This includes requesting MVR's from any state or country jurisdiction for the duration of employment for the purpose of the annual violations review (§391.23). *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
Information Requested:
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 requests@selection.com For employment or education verification purposes, email to releases@selection.com with the applicant’s full name in the subject line.
TRUCKING INDUSTRY: DOT D/A Disclosure and Authorization Send to Fax# (800) 257-8069
HireRight Customer:
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.
ATTACHMENT A 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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