Signature

I AUTHORIZE YOU TO MAKE SUCH INVESTIGATIONS AND INQUIRIES OF MY PERSONAL, EMPLOYMENT, FINANCIAL OR MEDICAL HISTORY AND OTHER RELATED MATTERS AS MAY BE NECESSARY IN ARRIVING AT AN EMPLOYMENT DECISION. (Generally, inquiries regarding medical history will be made only if and after a conditional offer of employment has been extended). I hereby release employers, schools, health care 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(s) 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 49CFR 391.23(d) and (e). I understand that 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.

Signature

Signature Date

Personal Details

Past years of residency

2020 Residency
2019 Residency
2018 Residency
2017 Residency

EMPLOYMENT HISTORY

All applicants wishing to drive in interstate commerce must provide the following information on all employers during the preceding three years. You must give the same information for all employers for whom you have driven a commercial vehicle seven years prior to the initial three years (total of ten years employment record).
You are required to list the complete mailing address: street number and name, city, state and zip code:
Current or Last Employer

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?

*Any gaps in employment and/or unemployment must be explained.
**The Federal Motor Carrier Safety Regulations (FMCSR’s) apply to anyone operating a motor vehicle on a highway in interstate commerce to transport passengers or property when the vehicle: (1) weighs or has a GVWR of 10,001 pounds or more, (2) is designed or used to transport 9 or more passengers, OR (3) is of any size and is used to transport hazardous materials in a quantity requiring placarding.
Second Last Employer

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?

*Any gaps in employment and/or unemployment must be explained.
**The Federal Motor Carrier Safety Regulations (FMCSR’s) apply to anyone operating a motor vehicle on a highway in interstate commerce to transport passengers or property when the vehicle: (1) weighs or has a GVWR of 10,001 pounds or more, (2) is designed or used to transport 9 or more passengers, OR (3) is of any size and is used to transport hazardous materials in a quantity requiring placarding.
Third Last Employer

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?

*Any gaps in employment and/or unemployment must be explained.
**The Federal Motor Carrier Safety Regulations (FMCSR’s) apply to anyone operating a motor vehicle on a highway in interstate commerce to transport passengers or property when the vehicle: (1) weighs or has a GVWR of 10,001 pounds or more, (2) is designed or used to transport 9 or more passengers, OR (3) is of any size and is used to transport hazardous materials in a quantity requiring placarding.
Fourth Last Employer

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?

*Any gaps in employment and/or unemployment must be explained.
**The Federal Motor Carrier Safety Regulations (FMCSR’s) apply to anyone operating a motor vehicle on a highway in interstate commerce to transport passengers or property when the vehicle: (1) weighs or has a GVWR of 10,001 pounds or more, (2) is designed or used to transport 9 or more passengers, OR (3) is of any size and is used to transport hazardous materials in a quantity requiring placarding.
Fifth Last Employer

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?

*Any gaps in employment and/or unemployment must be explained.
**The Federal Motor Carrier Safety Regulations (FMCSR’s) apply to anyone operating a motor vehicle on a highway in interstate commerce to transport passengers or property when the vehicle: (1) weighs or has a GVWR of 10,001 pounds or more, (2) is designed or used to transport 9 or more passengers, OR (3) is of any size and is used to transport hazardous materials in a quantity requiring placarding.

EXPERIENCE AND QUALIFICATION

Commercial Truck Driving Experience

Commerical Truck Driving Equipment Experience

Straight Truck

Type of Equipment
(Check All That Apply)

Tractor & Semi-Trailer

Type of Equipment
(Check All That Apply)

Tractor - Two Trailers

Type of Equipment
(Check All That Apply)

Tractor - Three Trailers

Type of Equipment
(Check All That Apply)

Motorcoach / Bus
( more than 8 passenger)

Type of Equipment
(Check All That Apply)

Motorcoach / Bus
( more than 15 passenger)

Type of Equipment
(Check All That Apply)

Other

Type of Equipment
(Check All That Apply)

Accident History (3 Years)

Accident
in a Commercial Truck

Hazardous Materials Spill?

Vehicle Tow Away?

Accident
in a Commercial Truck

Hazardous Materials Spill?

Vehicle Tow Away?

Accident
in a Commercial Truck

Hazardous Materials Spill?

Vehicle Tow Away?

Traffic Convictions and Forfeitures (3 Years)

2020 Conviction(s) / Forfeiture(s)
(Forfeited bond, collateral and/or points)
2019 Conviction(s) / Forfeiture(s)
(Forfeited bond, collateral and/or points)
2018 Conviction(s) / Forfeiture(s)
(Forfeited bond, collateral and/or points)
License Information

Have you ever been denied a license, permit, or privilege to operate a motor vehicle?

Has any license, permit, or privilege ever been suspended or revoked?

IMPORTANT DISCLOSURE
REGARDING BACKGROUND REPORTS
FROM THE PSP Online Service

In connection with your application for employment with UNITED METALS LLC (“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 TO REQUEST DRIVING RECORD

The following statement quoted below will be used with your signature and date (signed at the top of this form) to request your Driving Record from the U.S. Department of Transportation, Federal Motor Carrier Safety Administration (FMCSA).

I hereby authorize you to release the following information to UNITED METALS LLC, for the purpose of investigation as required by Section 391.23 of the Federal Motor Carrier Safety Regulations. You are released from any and all liability which may result from furnishing such information.

FMCSA Authorization