Trucking Application - Part 2

FORM DQF04 - CONSENT FOR RELEASE OF DRUG AND ALCOHOL TESTING INFORMATION AND TREATMENT RECORDS AND SAFETY PERFORMANCE HISTORY

Name(Required)
APPLICANT: IF YOU ARE CURRENTLY OR WERE EMPLOYED BY A DOT REGULATED EMPLOYER DURING THE LAST THREE YEARS AND PERFORMED A SAFETY SENSITIVE FUNCTION FOR THAT EMPLOYER, PLEASE PROVIDE THE NAME OF THAT EMPLOYER, A COMPLETE MAILING ADDRESS, PHONE AND FAX NUMBER STARTING WITH THE AREA CODE. START WITH THE MOST RECENT EMPLOYER FIRST.
MM slash DD slash YYYY
MM slash DD slash YYYY
Address
Were you subject to the FMCSRs while employed?
Was your job designated as a safety-sensitive function in any dot-regulated mode subject to the drug and alcohol testing requirements of 49 CFR part 40?

MM slash DD slash YYYY
MM slash DD slash YYYY
Address
Were you subject to the FMCSRs while employed?
Was your job designated as a safety-sensitive function in any dot-regulated mode subject to the drug and alcohol testing requirements of 49 CFR part 40?

MM slash DD slash YYYY
MM slash DD slash YYYY
Address
Were you subject to the FMCSRs while employed?
Was your job designated as a safety-sensitive function in any dot-regulated mode subject to the drug and alcohol testing requirements of 49 CFR part 40?

MM slash DD slash YYYY
MM slash DD slash YYYY
Address
Were you subject to the FMCSRs while employed?
Was your job designated as a safety-sensitive function in any dot-regulated mode subject to the drug and alcohol testing requirements of 49 CFR part 40?

MM slash DD slash YYYY
MM slash DD slash YYYY
Address
Were you subject to the FMCSRs while employed?
Was your job designated as a safety-sensitive function in any dot-regulated mode subject to the drug and alcohol testing requirements of 49 CFR part 40?

MM slash DD slash YYYY
MM slash DD slash YYYY
Address
Were you subject to the FMCSRs while employed?
Was your job designated as a safety-sensitive function in any dot-regulated mode subject to the drug and alcohol testing requirements of 49 CFR part 40?

MM slash DD slash YYYY
MM slash DD slash YYYY
Address
Were you subject to the FMCSRs while employed?
Was your job designated as a safety-sensitive function in any dot-regulated mode subject to the drug and alcohol testing requirements of 49 CFR part 40?

MM slash DD slash YYYY
MM slash DD slash YYYY
Address
Were you subject to the FMCSRs while employed?
Was your job designated as a safety-sensitive function in any dot-regulated mode subject to the drug and alcohol testing requirements of 49 CFR part 40?

MM slash DD slash YYYY
MM slash DD slash YYYY
Address
Were you subject to the FMCSRs while employed?
Was your job designated as a safety-sensitive function in any dot-regulated mode subject to the drug and alcohol testing requirements of 49 CFR part 40?

MM slash DD slash YYYY
MM slash DD slash YYYY
Address
Were you subject to the FMCSRs while employed?
Was your job designated as a safety-sensitive function in any dot-regulated mode subject to the drug and alcohol testing requirements of 49 CFR part 40?

FORM DQF04 - CONSENT FOR RELEASE OF DRUG AND ALCOHOL TESTING INFORMATION AND TREATMENT RECORDS AND SAFETY PERFORMANCE HISTORY

I authorize my above listed previous employers to disclose to FS Solutions or its designated agents information pertaining to my safety performance history with Department of Transportation regulated employers during the preceding three years. This will include any verified positive drug test result, any alcohol test result of .04 or above, any refusal to test (including verified adulterated or substituted drug test results), any other violation of Department of Transportation (DOT) agency drug and alcohol testing regulations and any records of evaluation and treatment, to include completion of DOT return to duty requirements, resulting from such violations or tests, conducted on me in accordance with 49 CFR Part 391, section 391.23(e), This will also include accident data as described in 49 CFR Part 391, section 391.23(d). I further authorize Background Check to disclose this information to the prospective employer listed below and agree to hold harmless any previous employers listed above, Background Check, its directors, employees, agents, or volunteers for any damage, loss of employment, or any negative outcome that may result from such disclosure. I understand that the prospective employer listed below is required to obtain this information in accordance with Federal regulations, specifically 49 CFR Part 391, section 391.23. This consent is subject to revocation at any time, however, such revocation does not apply to disclosures made prior to notice. This authorization expires without express revocation sixty (60) days from the date that appears below. I understand that I have the right to inspect and copy any written information disclosed.
Clear Signature


Notice to Applicants/Employees Regarding Consumer Reports



A consumer report and/or an investigative consumer report including information concerning your character, employment history, general reputation, personal characteristics, police record, education, qualifications, motor vehicle record, mode of living, and/or credit and indebtedness may be obtained in connection with your application for and/or continued employment with the company. A consumer report and/or an investigative consumer report may be obtained at any time during the application process or during your employment with the Company. A consumer report containing injury and illness records and medical information may be obtained after a tentative offer of employment has been made. Upon timely written request of the Personnel Department of the Company, and within 5 days of the request, the name, address and phone number of the reporting agency and the nature and scope of the investigative consumer report will be disclosed to you.

Before any adverse action is taken, based in whole or in part on the information contained in the consumer report, you will be provided a copy of the report, the name, address and telephone number of the reporting agency, a summary of your rights under the Fair Credit Reporting Act, as well as additional information on your rights under the law.

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DISCLOSURE AND AUTHORIZATION

IMPORTANT - PLEASE READ CAREFULLY BEFORE SIGNING AUTHORIZATION
DISCLOSURE REGARDING BACKGROUND INVESTIGATION

As part of the employment process, JRT Trucking, Inc. ("the Company") who is a vendor or service provider and its client {the "Sponsor'') may obtain information about you for employment purposes from a third party consumer reporting agency. Thus, you may be the subject of a "consumer report" and/or an "investigative consumer report" which may include information about your character, general reputation, personal characteristics, and/or mode of living, and which can involve personal interviews with sources such as your neighbors, friends, or associates. These reports may contain information regarding your credit history, criminal history, social security verification, motor vehicle records ("driving records"), verification of your education or employment history, or other background checks. Credit history will only be requested where such information is related to the duties and responsibilities of the position for which you are applying. You have the right, upon written request made within a reasonable time after receipt of this notice, to request disclosure of the nature and scope of any investigative consumer report and a copy of any report about you. Please be advised that the nature and scope of the most common form of investigative consumer report obtained with regard to applicants for employment is an investigation into your education and/or employment history conducted by )_________________, P.O. Box 105108, Atlanta, GA 30348-5108,1-800-845-6004, www.lDGY.com/risk/solutions. The scope of this notice and authorization is allencompassing, however, allowing the Company and Sponsor to obtain from any outside organization all manner of consumer reports and investigative consumer reports now and throughout the course of your employment to the extent permitted by law. As a result, you should carefully consider whether to exercise your right to request disclosure of the nature and scope of any investigative consumer report.
New York and Maine applicants or employees only: You have the right to inspect and receive a copy of any investigative consumer report requested by the Company by contacting the consumer reporting agency identified above directly. You may also contact the Company to request the name, address and telephone number of the nearest unit of the consumer reporting agency designated to handle inquiries, which the Company shall provide within 5 days.

ACKNOWLEDGMENT AND AUTHORIZATION

I acknowledge receipt of the DISCLOSURE REGARDING BACKGROUND INVESTIGATION and A SUMMARY OF YOUR RIGHTS UNDER THE FAIR CREDIT REPORTING ACT and certify that I have read and understand both of those documents. I hereby authorize the obtaining of "consumer reports" and/or "investigative consumer reports" by the Company and Sponsor at any time after receipt of this authorization and throughout my employment, if applicable. To this end, I hereby authorize, without reservation, any law enforcement agency, administrator, state or federal agency, institution, school or university (public or private), information service bureau, employer, or insurance company to furnish any and all background information requested by )______________., P.O. Box 105108, Atlanta, GA 30348-5108,1-800-845-6004, www.lDGY.com/risk/solutions, another outside organization acting on behalf of the Company, and/or the Company itself. )___________ Privacy Policy: KWWS://ZZZ.IDGY.FRP/SULYDF\-SROLFVscreen.html. I agree that a facsimile ("fax"), electronic or photographic copy of this Authorization shall be as valid as the original.

New York applicants or employees only: By signing below, you also acknowledge receipt of Article 23-A of the New York Correction Law.

Minnesota and Oklahoma applicants or employees only:
Please check this box if you would like to receive a copy of a consumer report at no charge if one is obtained by the Company.

California applicants or employees only: By signing below, you also acknowledge receipt of the NOTICE REGARDING BACKGROUND INVESTIGATION PURSUANT TO CALIFORNIA LAW.

Please check this box if you would like to receive a copy of an investigative consumer report or consumer credit report at no charge if one is obtained by the Company whenever you have a right to receive such a copy under California law.

Washington State applicants or employees only: You also have the right to request from the consumer reporting agency a written summary of your rights and remedies under the Washington Fair Credit Reporting Act

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Employer please note: If a Minnesota or Oklahoma consumer checks "YES" regarding the consumer report, or if a California consumer checks "YES" regarding the credit report (and you do request a credit report), please fax this form to your service center. If consumer checks "YES" regarding the full consumer report, and consumer resides in California, you will need to provide the individual with a copy of their consumer report, unless you have made prior arrangements to do so on your behalf. Account Number:

Consumer Information

Present Address
*This information will be used for background screening purposes only and will not be used as hiring criteria
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DISCLOSURE REGARDING BACKGROUND INVESTIGATION

JRT Trucking, Inc. may obtain information about you from a third party consumer reporting agency (CRA) for employment purposes. This information may be obtained in the form of a "consumer report" and/or an "investigative consumer report" (commonly known as a ''background report''). These reports may contain information regarding your criminal history, social security verification, motor vehicle records ("driving records"), credit history*, verification of your education or employment history, drug screening or other background checks. This information may be obtained from private and public record sources, including, as appropriate: government agencies and courthouses and educational institutions. The reports may also include information about your character, general reputation, personal characteristics, mode of living, etc., which can involve personal interviews with individuals or companies that you have listed as a reference, former employer, etc. A more comprehensive background investigation may be required pursuant to state or federal law, contract agreement or for certain sensitive positions (such as those with significant financial responsibilities). (*Please note that credit history will only be requested where such information is substantially related to the duties and responsibilities of the position for which you are applying.)

You have the right, upon written request made within a reasonable time, to request whether a consumer report has been run about you, disclosure of the nature and scope of any investigative consumer report and to request a copy of your report. Please be advised that the nature and scope of any investigative consumer report obtained with regard to applicants for employment is an investigation conducted by FSSolutions.

FSSolutions can be contacted via mail, phone or email at: FSSolutions
1192 Hansen Road Ste 100
Green Bay, WI 54304
Phone: 855.610.9373
[email protected]

Clear Signature

ACKNOWLEDGMENT AND AUTHORIZATION FOR BACKGROUND CHECK

I acknowledge receipt of the separate document entitled "Disclosure Regarding Background Investigation" and "A Summary of Your Rights under the Fair Credit Reporting Act" and certify that I have read and understand both of those documents I hereby authorize the obtaining of "consumer reports" and/or investigative consumer reports" by the Company at any time after receipt of this authorization and throughout my employment, or status as an Advisor, if applicable. To this end, I hereby authorize, without reservation, any law enforcement agency, administrator, state or federal agency, institution, school or university (public or private), information service bureau, employer, or insurance company to furnish any and all drug screening and background information requested by FSSolutions 1192 Hansen Road Ste 100 Green Bay, WI 54305 855.610.9373, www.firstsourcesolutions.com and/or the Company itself I agree that a facsimile ("fax"), electronic or photographic copy of this Authorization shall be as valid as the original.
New York applicants only: Upon request, you will be informed whether or not a consumer report was requested by the Company, and if such report was requested, informed of the name and address of the consumer reporting agency that furnished the report. You have the right to inspect and receive a copy of any investigative consumer reports requested by the Company by contacting the consumer reporting agency identified above directly. By signing below, you acknowledge receipt of Article 23-A of the New York Correction Law
Washington State applicants only: You also have the right to request from the consumer reporting agency a written summary of your rights and remedies under the Washington Fair Credit Reporting Act.
Minnesota and Oklahoma applicants only: Please check this box if you would like to receive a copy of a consumer report if one is obtained by the Company.
California applicants only:
Under California Civil Code section 1786.22, you are entitled to find out what is in the CRA's file on you with proper identification, as follows:
  • In person, by visual inspection of your file during normal business hours and on reasonable notice. You also may request a copy of the information in person. The CRA may not charge you more than the actual copying costs for providing you with a copy of your file.
  • A summary of all information contained in the CRA file on you that is required to be provided by the California Civil Code will be provided to you via telephone, if you have made a written request, with proper identification, for telephone disclosure, and the toll charge, if any, for the telephone call is prepaid by or charged directly to you.
  • By requesting a copy be sent to a specified addressee by certified mail. CRAs complying with requests for certified mailings shall not be liable for disclosures to third parties caused by mishandling of mail after such mailings leave the CRAs.

"Proper Identification" includes documents such as a valid driver's license, social security account number, military identification card, and credit cards. Only if you cannot identify yourself with such information may the CRA require additional information concerning your employment and personal or family history in order to verify your identity. The CRA will provide trained personnel to explain any information furnished to you and will provide a written explanation of any coded information contained in files maintained on you. This written explanation will be provided whenever a file is provided to you for visual inspection. You may be accompanied by one other person of your choosing, who must furnish reasonable identification. A CRA may require you to furnish a written statement granting permission to the CRA to discuss your file in such person's presence.

Please check this box if you would like to receive a copy of an investigative consumer report or consumer credit report at no charge if one is obtained by the Company whenever you have a right to receive such a copy under California law.

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