Drive for AVL – Step 1 DRIVER APPLICATION FORMAPPLICANT INFORMATIONLast Name:* First Name:* Middle Name: Address:* Apt: City:* State:* Zip:* # Years: Phone:*Email:* Social Security Number: DOB:*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920TO BE READ AND SIGNED BY APPLICANTI authorize you to make such investigations and inquires of my personal, employment, financial or medical history and other related matters as may be necessary in arriving at an employment decision. (Generally, inquired regarding medical history will be made only if and after a conditional offer of employment has been extended). I hereby release employers, schools, healthcare providers and other persons from all liability in responding to inquiries and releasing information in connection with my application. In the event of employment, I understand that false or misleading information given in my application or interview may result in discharge. I understand also, that I am required to abide by all rules and regulations of the Company. I understand that information I provide regarding current and/or previous employers may be used, and those employer(s) will be contacted, for the purpose of investigating my safety performance history as required by 49 CFR 391.23(d) and (e). I understand I have the right to: Review information provided by current/previous employers; Have errors in the information corrected by previous employers and for those previous employers to re-send the corrected information to the prospective employer, and; Have a rebuttal statement attached to the alleged erroneous information, if the previous employer(s) and I cannot agree on the accuracy of the information.Applicant Signature*This signature equivalent to an electronic signatureDate:* MM slash DD slash YYYY EMPLOYMENT HISTORYCompany: Phone:Address: Supervisor: City: State: Zip: Job Title: From MM slash DD slash YYYY To MM slash DD slash YYYY Account for period between jobs – Include dates (month/year) and reason:Where you subject to the Federal Motor Carrier Safety Regulations while employed Yes No 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? Yes No ADDITIONAL EMPLOYMENT HISTORY INFORMATIONEMPLOYMENT HISTORYCompany: Phone:Address: Supervisor: City: State: Zip: Job Title: From: MM slash DD slash YYYY To: MM slash DD slash YYYY Account for period between jobs – Include dates (month/year) and reason:Where you subject to the Federal Motor Carrier Safety Regulations while employed Yes No 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? Yes No EMPLOYMENT HISTORYCompany: Phone:Address: Supervisor: City: State: Zip: Job Title: From: MM slash DD slash YYYY To: MM slash DD slash YYYY Account for period between jobs – Include dates (month/year) and reason:Where you subject to the Federal Motor Carrier Safety Regulations while employed Yes No 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? Yes No EMPLOYMENT HISTORYCompany: Phone:Address: Supervisor: City: State: Zip: Job Title: From: MM slash DD slash YYYY To: MM slash DD slash YYYY Account for period between jobs – Include dates (month/year) and reason:Where you subject to the Federal Motor Carrier Safety Regulations while employed Yes No 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? Yes No EXPERIENCE AND QUALIFICATIONDRIVING EXPERIENCE – Check here If no driving experience within the last 3 years Straight TruckFrom MM slash DD slash YYYY To MM slash DD slash YYYY Approx. # of Miles: Tractor & Semi TrailerFrom MM slash DD slash YYYY To MM slash DD slash YYYY Approx. # of Miles: Tractor – Two TrailersFrom MM slash DD slash YYYY To MM slash DD slash YYYY Approx. # of Miles: Tractor – Three TrailersFrom MM slash DD slash YYYY To MM slash DD slash YYYY Approx. # of Miles: Motor Coach – School Bus From MM slash DD slash YYYY To MM slash DD slash YYYY Approx. # of Miles: Motor Coach – PassengerFrom MM slash DD slash YYYY To MM slash DD slash YYYY Approx. # of Miles: Other: From MM slash DD slash YYYY To MM slash DD slash YYYY Approx. # of Miles: ACCIDENT HISTORY (3 Years) Check here If no accidents within the last 3 years Date (Month/Year)Nature of Accident# Fatalities# InjuriesTow TRAFFIC CONVICTIONS & FORFEITURES (3 Years) Check here If no traffic convictions and/or forfeitures in the last 3 years Date ConvictedViolationState of ViolationPenalty/Points LICENSE INFORMATION – Section 383.21 FMCSR states “No person who operates a commercial motor vehicle shall at any time have more than one driver’s license”. I certify that I do not have more than one motor vehicle license, the information for which is listed below:State:* License Number:* Exp Date:* MM slash DD slash YYYY 1. Have you ever been denied a license, permit, or privilege to operate a motor vehicle?* Yes No 2. Has any license, permit or privilege ever been suspended or revoked?* Yes No Applicant Certification: This certifies 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:Applicant Signature*This signature equivalent to an electronic signatureDate:* MM slash DD slash YYYY DISCLOSURE AND AUTHORIZATION FORMA background investigation will be requested from consumer reporting agencies in connection with your employment DISCLOSURE AND AUTHORIZATION FORM application for employment purposes. This information may be obtained in the form of consumer reports and/or investigative consumer reports. These reports may be obtained at any time after receipt of your authorization, and if you are hired by the Company, throughout your employment. FAIR CREDIT REPORT ACT 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 I, of Public Law 104-208), you are being informed that reports verifying your previous employment, previous drug and alcohol test results, criminal background and driving records 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. I have carefully read and understand this Disclosure and Authorization form. By my signature below, I consent to the release of consumer reports and investigative consumer reports prepared by a consumer reporting agency, such as to the Company and its designated representatives and agents. I understand that if the Company hires me, my consent will apply, and the Company may obtain reports, throughout my employment. I also understand that information contained in my job application or otherwise disclosed by me before or during my employment, if any, may be used for the purpose of obtaining consumer reports and/or investigative consumer reports. By my signature below, I authorize law enforcement agencies, learning institutions (including public and private schools and universities), information service bureaus, credit bureaus, record/data repositories, courts (federal, state and local), motor vehicle records agencies, my past or present employers, the military, and other individuals and sources to furnish any and all information on me that is requested by the consumer reporting agency. By my signature below, I certify the information I provided on this form is true and correct. I agree that this Disclosure and Authorization form in original, faxed, photocopied or electronic (including electronically signed) form, will be valid for any reports that may be requested by or on behalf of the Company. American Van Lines IncApplicant Last Name:* First:* Middle:* Social Security #:* Date of Birth* MM slash DD slash YYYY Present Address:* How Long:* City/State/Zip:* Prior Address: From MM slash DD slash YYYY To MM slash DD slash YYYY Driver’s License #:* State:* Prior License within 3 years:* State:* Applicant Signature*This signature equivalent to an electronic signatureDate:* MM slash DD slash YYYY This document must be maintained in the driver’s qualification file and may be purged after 3 years from the date of execution. THE BELOW DISCLOSURE AND AUTHORIZATION LANGUAGE IS FOR MANDATORY USE BY ALL ACCOUNT HOLDERSIMPORTANT DISCLOSUREREGARDING BACKGROUND REPORTS FROM THE PSP Online Service In connection with your application for employment with AMERICAN VAN LINES INC (“Prospective Employer”), 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. AUTHORIZATION If you agree that the Prospective Employer may obtain such background reports, please read the following and sign below: I authorize AMERICAN VAN LINES INC (“Prospective Employer”) 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 and inspection 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. I 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 DataQs 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.Name (Please Print)* Date:* MM slash DD slash YYYY Signature*This signature equivalent to an electronic signatureNOTICE: 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 in whole, exactly as provided. 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 49 C.F.R. 383.5. THIS RELEASE FORM LAST UPDATED 12/22/2015 – ALTERATION OF ANY KIND IS NOT PERMITTEDGENERAL CONSENT FOR LIMITED QUERIES OF FMCSA DRUG & ALCOHOL CLEARINGHOUSE I, hereby provide consent to AMERICAN VAN LINES INC/TPA SUNCOAST TRUCKING COMPLIANCE INC to conduct a limited query of the FMCSA Commercial Driver’s License Drug and Alcohol Clearinghouse to determine whether drug or alcohol violation information about me exists in the Clearinghouse. This consent will be for valid for multiple limited queries for the entire duration of my employment with AMERICAN VAN LINES INC/TPA SUNCOAST TRUCKING COMPLIANCE INC. I understand that if the limited query conducted by AMERICAN VAN LINES INC/TPA SUNCOAST TRUCKING COMPLIANCE INC indicates that drug or alcohol violation information about me exists in the Clearinghouse, FMCSA will not disclose that information to AMERICAN VAN LINES/TPA SUNCOAST TRUCKING COMPLIANCE INC without first obtaining additional specific consent from me. I further understand that if I refuse to provide consent for AMERICAN VAN LINES/TPA SUNCOAST TRUCKING COMPLIANCE INC to conduct a limited query of the Clearinghouse, AMERICAN VAN LINES INC must prohibit me from performing safety-sensitive functions, including driving a commercial motor vehicle, as required by FMCSA’s drug and alcohol program regulations. Name (Please Print)* Date:* MM slash DD slash YYYY Signature*This signature equivalent to an electronic signature Δ
