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From - Prospective Employer/Contractor | To - previous employer |
---|---|
Dear Motor Carrier:
The person listed below has made application to this company for employment or contracting as a Driver and states that he/she was employed by you as from to . If these dates are not correct please provide From and To The applicant has waived any claim of liability against you company for information submitted in response to the inquiry - See release form at
bottom of this page
Name of Applicant:
6. Number of accidents Number preventable
I hereby authorize you to release all information regarding my services, character and conduct while in your employ, and you are released from any and all liablility which may result from furnishing such information.
Previous Employer:
Name:
Address:
Phone:
Email:
Fax:
Applicant
Applicant Name: Social Security: Date of Birth:
Date of Employment: From: To
Prospective Employer/Contractor:
Wolfpack Drivers, Inc.
9431 Haven Avenue Suite 100 Rancho Cucamonga California 91730
Confidential Email:
Confidential Fax:
Prospective Employer's/Contractor's Agent
Confidential Email:
Confidential Fax:
I, hereby authorize to release and forward the information requested in sections2 and 3 of this document concerning my Accident History within the previous 3 years to (Prospective Employer/Contractor), and/or (third-party investigation firm).
This information is being requested in compliance with 49 CFR $$ 40.25 and 391.23.
In compliance with 49 CFR $$40.25(g) and 391.23(h), release of this information must be made in a form that ensures confidentiality, such as fax, email, or letter.
The applicant named above was employed by you.
ACCIDENTS: Complete the following for any accidents included on your accident registrar ($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 register data for this driver.
Date | Location | Number of Injuries |
Number of Fatalities |
Hazmat Spill |
Preventable | Description |
Please provide information concerning any other accidents involving the applicant that were reported to government agencies or insurers or retained under internal company policies:
Name: | |
Company: | |
Street: | |
City, State, Zip: | |
Phone: | |
Date: |
In connection with your application for employment with , Prospective Employer, its employees, agents or contractors may obtain one or more reports regarding your driving, and safety inspection history from the Federal Motor Carrier Safety Administration (FMCSA).
When the application for employment is submitted in person, if the Prospective Employer uses any information it obtains from FMCSA in a decision to not hire you or to make any other adverse employment decision regarding you, the Prospective Employer will provide you with a copy of the report upon which its decision was based and a written summary of your rights under the Fair Credit Reporting Act before taking any final adverse action. If any final adverse action is taken against you based upon your driving history or safety report, the Prospective Employer will notify you that the action has been taken and that the action was based in part or in whole on this report.
When the application for employment is submitted by mail, telephone, computer, or other similar means, if the Prospective Employer uses any information it obtains from FMCSA in a decision to not hire you or to make any other adverse employment decision regarding you, the Prospective Employer must provide you within three business days of taking adverse action oral, written or electronic notification: that adverse action has been taken based in whole or in part on information obtained from FMCSA; the name, address, and the toll free telephone number of FMCSA; that the FMCSA did not make the decision to take the adverse action and is unable to provide you the specific reasons why the adverse action was taken; and that you may, upon providing proper identification, request a free copy of the report and may dispute with the FMCSA the accuracy or completeness of any information or report. If you request a copy of a driver record from the Prospective Employer who procured the report, then, within 3 business days of receiving your request, together with proper identification, the Prospective Employer must send or provide to you a copy of your report and a summary of your rights under the Fair Credit Reporting Act
Neither the Prospective Employer nor the FMCSA contractor supplying the crash and safety information has the capability to correct any safety data that appears to be incorrect. You may challenge the accuracy of the data by submitting a request to https://dataqs.fmcsa.dot.gov. If you challenge crash or inspection information reported by a State, FMCSA cannot change or correct this data. Your request will be forwarded by the DataQs system to the appropriate State for adjudication.
Any crash or inspection in which you were involved will display on your PSP report. Since the PSP report does not report, or assign, or imply fault, it will include all Commercial Motor Vehicle (CMV) crashes where you were a driver or co-driver and where those crashes were reported to FMCSA, regardless of fault. Similarly, all inspections, with or without violations, appear on the PSP report. State citations associated with Federal Motor Carrier Safety Regulations (FMCSR) violations that have been adjudicated by a court of law will also appear, and remain, on a PSP report.
The Prospective Employer cannot obtain background reports from FMCSA without your authorization.
The release and authorization acknowledge that Wolfpack Drivers, Inc. located at 9431 Haven Avenue Suite 100 may now, or at any time while I am employed, conduct a verification of my education, employment history, social security, credit history, motor vehicle records, contact my personal references, and receive any criminal history record information pertaining to me which may be in the files of any Federal, State, or Local criminal justice agency in any state, and/or other information as deemed necessary to fulfill the job requirements. Also, if an offer of employment has been made, I authorize review of my worker's compensation claims history.
I authorize located at to disclose orally and in writing the results of the verification process to the designated authorized representative of Wolfpack Drivers, Inc.. The results will be used to determine employment eligibility under this company's employment policies.
I have read and understand this release and consent, and I authorize the background verifications. I authorize persons, schools, current and former employers, and other organizations and agencies to provide agents of my prospective employer with all information that may be requested, and I hereby release all of the persons and agencies providing such information from any and all claims and damages connected with their release of any requested information. I agree that any copy of this document is as valid as the original.
I do hereby agree to forever release and discharge Wolfpack Drivers, Inc., , and their associates to the full extent permitted by-law from any claims, damages, losses, liability, costs, and expenses, or any other charge or complaint filed with any agency arising from the retrieving and reporting of information. According to the Federal Fair Credit Reporting Act, I am entitled to know if employment was denied as a result of information obtained by my prospective employer, and to receive, upon written request, a disclosure of the pubic record information and of the nature and scope of the investigative report.
Investigative Consumer Report:
Wolfpack Drivers, Inc., (the “Company”) may request an investigative consumer report about you from , a consumer reporting agency, in connection with your employment, or application for employment, or engagement for services (including independent contractor or volunteer assignments, as applicable). An “investigative consumer report” is a background report that includes information from personal interviews (except in California, where that term includes background reports with or without information obtained from personal interviews), the most common form of which is checking personal or professional references through personal interviews with sources such as your former employers and associates, and other information sources. The investigative consumer report may contain information concerning your character, general reputation, personal characteristics, mode of living, or credit standing. You may request more information about the nature and scope of an investigative consumer report, if any, by contacting the Company.
Ongoing Authorization:
If the Company hires you or contracts for your services, the Company may obtain additional consumer reports and investigative consumer reports about you without asking for your authorization again, throughout your employment or your contract period, as allowed by law.
Additional State Law Notices:
Please see the “Additional State Law Notices” for California, Massachusetts, Minnesota, New Jersey, New York, and Washington that are provided below, as applicable.
I understand that as required by the Federal Motor Carrier Safety Regulations, Title 49 United States Code of Federal Regulations, Section 391.103 and Wolfpack Drivers, Inc. company policy, all prospective drivers must submit to a controlled substances test.
I agree to provide a urine sample at a location and time designated by Wolfpack Drivers, Inc., to be tested for controlled substances.
I also understand that if I test positive for use of controlled substances, I am not medically qualified to operate a commercial motor vehicle or perform safety-sensitive functions.
I also understand that the results of the controlled substances test will be examined by a Medical Review Officer who will report the test results to Wolfpack Drivers, Inc. and/or its screening agents, including , ,. My results will not be released to any additional parties without my written authorization.
I agree to hold harmless Wolfpack Drivers, Inc. and its agents from any liability with regard to the collection and testing of my specimens, or the use of my controlled substance test results in connection with my employment or consideration for employment.
Para información en español, visite www.consumerfinance.gov/learnmore o escribe a la Consumer Financial Protection Bureau, 1700 G Street N.W., Washington, DC 20552.
The Federal Fair Credit Reporting Act (FCRA) promotes the accuracy, fairness, and privacy of information in the files of consumer reporting agencies. There are many types of consumer reporting agencies, including credit bureaus and specialty agencies (such as agencies that sell information about check writing histories, medical records, and rental history records). Here is a summary of your major rights under the FCRA. For more information, including information about additional rights, go to www.consumerfinance.gov/learnmore or write to: Consumer Financial Protection Bureau, 1700 G Street N.W., Washington, DC 20552.
States may enforce the FCRA, and many states have their own consumer reporting laws. In some cases, you may have more rights under state law. For more information, contact your state or local consumer protection agency or your state Attorney General. For information about your federal rights, contact:
TYPE OF BUSINESS: | CONTACT: |
1.a. Banks, savings associations, and credit unions with total assets of over $10 billion and their affiliates | a. Consumer Financial Protection Bureau 1700 G Street, N.W. Washington, DC 20552 |
b. Such affiliates that are not banks, savings associations, or credit unions also should list, in addition to the CFPB: | b. Federal Trade Commission Consumer Response Center 600 Pennsylvania Avenue, N.W. Washington, DC 20580 |
2. To the extent not included in item 1 above: a. National banks, federal savings associations, and federal branches and federal agencies of foreign banks |
a. Office of the Comptroller of the Currency Customer Assistance Group 1301 McKinney Street, Suite 3450 Houston, TX 77010-9050 |
b. State member banks, branches and agencies of foreign banks (other than federal branches, federal agencies, and Insured State Branches of Foreign Banks), commercial lending companies owned or controlled by foreign banks, and organizations operating under section 25 or 25A of the Federal Reserve Act. | b. Federal Reserve Consumer Help Center P.O. Box 1200 Minneapolis, MN 55480 |
c. Nonmember Insured Banks, Insured State Branches of Foreign Banks, and insured state savings associations | c. FDIC Consumer Response Center 1100 Walnut Street, Box #11 Kansas City, MO 64106 |
d. Federal Credit Unions | d. National Credit Union Administration Office of Consumer Financial Protection (OCFP) Division of Consumer Compliance Policy and Outreach 1775 Duke Street Alexandria, VA 22314 |
3. Air carriers | Asst. General Counsel for Aviation Enforcement & Proceedings Aviation Consumer Protection Division Department of Transportation 1200 New Jersey Avenue, S.E. Washington, DC 20590 |
4. Creditors Subject to the Surface Transportation Board | Office of Proceedings, Surface Transportation Board Department of Transportation 395 E Street, S.W. Washington, DC 20423 |
5. Creditors Subject to the Packers and Stockyards Act, 1921 | Nearest Packers and Stockyards Administration area supervisor |
6. Small Business Investment Companies | Associate Deputy Administrator for Capital Access United States Small Business Administration 409 Third Street, S.W., Suite 8200 Washington, DC 20416 |
7. Brokers and Dealers | Securities and Exchange Commission 100 F Street, N.E. Washington, DC 20549 |
8. Federal Land Banks, Federal Land Bank Associations, Federal Intermediate Credit Banks, and Production Credit Associations | Farm Credit Administration 1501 Farm Credit Drive McLean, VA 22102-5090 |
9. Retailers, Finance Companies, and All Other Creditors Not Listed Above | Federal Trade Commission Consumer Response Center 600 Pennsylvania Avenue, N.W. Washington, DC 20580 (877) 382-4357 |
I acknowledge that I have read and understand the federal FCRA Summary of Rights and have been given the opportunity to copy/print the Summary of Rights and agree to use an electronic signature to demonstrate my consent.
Motor carriers have the responsibility to make the following investigations and inquiries with respect to each driver employed, other than a person who has been a regularly employed driver of the motor carrier for a continuous period which began before January 1, 1971.
Drivers who wish to review previous employer-provided information must submit a written request to the prospective employer when applying of as late as 30 days after employed or being notified of denial of employment. The prospective employer must provide this information to the applicant within five business days of receiving the written request. If the driver has not arranged to pick up or receive the requested records within 30 days pf the prospective employer making them available, the prospective motor carrier may consider the driver to have waived his/her request to review the records.
Drivers wishing to request correction of erroneous information in records must send the request for the correction to the previous employer that provided the records. After October 29, 2004, the previous employer must either correct and forward the information to the prospective motor carrier employer or notify the driver within 15 days of receiving the driver's request to correct the data that it does not agree to correct the data. Drivers wishing to rebut information in records must send the rebuttal to the previous employer with instructions to include the rebuttal in the driver's Safety Performance History.
I acknowledge that I have read and understand the contents of this document.
I hereby authorize the motor carrier listed below to conduct limited annual queries of the FMCSA's Commercial Driver's License Drug and Alcohol Clearinghouse (Clearinghouse) to determine whether drug or alcohol violation information about me exists in the Clearinghouse. This consent is valid from the date shown below until my employment with the motor carrier listed below ceases or until I am no longer subject to the drug and alcohol testing rules in 49 CFR part 382 for the motor carrier listed below.
I understand that if the limited query conducted by this motor carrier indicates that drug or alcohol violation information about me exists in the Clearinghouse, I must grant electronic consent within 24 hours, via the Clearinghouse website, for the motor carrier to obtain my full Clearinghouse record.
I understand that if I refuse to provide consent to conduct annual limited queries of the Clearinghouse, the motor carrier must prohibit me from performing safety-sensitive functions, including driving a commercial motor vehicle, as required by FMCSA's drug and alcohol program regulations.
I further understand that if I refuse to grant electronic consent for my full Clearinghouse record within 24 hrs of a completed limited query which reveals that drug or alcohol violation information about me exist, the motor carrier must remove me from performing safety-sensitive functions.