Prospective Employer:
JRT Trucking, Inc.
1615 W Lenington Rd.
Sallisaw, OK 74955
918-612-4161
Previous 10 Year Work 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.
Driving Experience
Disclaimer & Signature
I certify that my answers are true and complete to the best of my knowledge.
If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release.
Minnesota and Oklahoma applicants or employees only:
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
*This information will be used for background screening purposes only and will not be used as hiring criteria
Sec. 40.25(j) As the employer, you must also ask the employee whether he or she has tested positive, or refused to test, on any pre-employment drug or alcohol test administered by an employer to which the employee applied for, but did not obtain, safety-sensitive transportation work covered by DOT agency drug and alcohol testing rules during the last two years. If the employee admits that he or she had a positive test or a refusal to test, you must not use the employee to perform safety-sensitive functions for you, until and unless the employee documents successful completion of the return-to-duty process. (see Sec. 40.25(b)(5) and (e))
If you answered yes, can you provide/obtain proof that you ;ve successfully completed the DOT return-to-duty requirements?
I certify that the information provided on this document is true and correct.
Witnessed by: _____________________________________________________________________________________
Date _____________________________________________