Trucking Application - Part 2

Form DQF04

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

Name(Required)
I hereby authorize release of information from my Department of Transportation regulated drug and alcohol testing records by my previous employer, listed above, to the employer and their agents listed below. This release is in accordance with the DOT Regulation 49 CFR Part 40, Section 40.25. I understand that information to be released by my previous employer is limited to the following DOT=regulated testing items:
  1. Alcohol tests with a result of 0.04 or higher;
  2. Verified positive drug tests;
  3. Refusals to be tested;
  4. Other violations of DOT agency drug and alcohol testing regulations;
  5. Information obtained from previous employers of a drug and alcohol rule violation;
  6. Documentation, if any, of completion of the return-to-duty process following a rule violation;
  7. Accident data is require by 49 CFR part 391.
Prospective Employer: JRT Trucking, Inc. 1615 W Lenington Rd. Sallisaw, OK 74955 918-612-4161

Previous 10 Year Work History

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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?

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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?

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.
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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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Driving Experience

Please include Class of Equipment, Type of Equipment, Date, Approx. Miles

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.
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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
Fair Credit Reporting Ace Disclosure Statement

In accordance with the provisions of Section 604(b)(2)(a) of the Fair Credit Reporting Act, Public Law 91-508, as amended by the Consumer Credit Reporting Act of 1996 (Title II, Subtitle D, Chapter 1, of Public Law 104-208), you are being informed that reports verifying your previous employment, previous drug and alcohol test results, and your driving record may be obtained on you for employment purposes. These reports are required by Sections 382.413, 391.23, and 391.25 of the Federal Motor Carrier Safety Regulations.

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Previous Pre-Employment Employee Alcohol and Drug Test Statement

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))
The Prospective employee is required by Sec. 40.25(j) to respond to the following questions
  1. have you tested positive, or refused to test, on any pre-employment drug or alcohol test administered by an employer to which you applied for, but did not obtain, safety-sensitive transportation work covered by DOT agency drug and alcohol testing rules during the past two years?
Check One
If you answered yes, can you provide/obtain proof that you ;ve successfully completed the DOT return-to-duty requirements?
Check One
I certify that the information provided on this document is true and correct.
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Witnessed by: _____________________________________________________________________________________ Date _____________________________________________
This field is for validation purposes and should be left unchanged.