JACKSONVILLEP: (904) 666-77507701 Hammond Blvd, Jacksonville, FL 32220CORPORATE OFFICEP: (386) 872-7200345 8th Street, Holly Hill, FL 32117EMPLOYMENTLooking to work at one of the top tow truck companies in the industry? Fill out the employment application below!Driver Application for Employment Step 1 of 714%Date of Application Date Format: MM slash DD slash YYYY SSNName* First Middle Initial Last Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Date of Birth Date Format: MM slash DD slash YYYY Email* Home PhoneCell PhoneHave you ever been employed by this company in the past?YesNoIf yes, please explain:Driving Position applying for:Longhaul (OTR)LocalRegionalHome DeliveryHub FeederTeamLocation applying for:Are currently working for any other employers, full time or part time?YesNoIf yes, please explain:Fair Credit Reporting Act Disclosure Statement In accordance with the provision 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, 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.Driver Notification This notice serves to fulfill the requirements of 49 CFR Part 391.23(i). Each motor carrier must notify each driver, who is regulated by the Department of Transportation, of their rights regarding investigative information that will be provided to a prospective employer. Drivers have:The right to review information provided by previous employers;The right to have errors in the information corrected by the previous employer and for that previous employer to re-send the corrected information to the prospective employer;The right to have a rebuttal statement attached to the alleged erroneous information, if the previous employer and the driver cannot agree on the accuracy of the information.Past Pre-Employment Drug & Alcohol Testing Question In accordance with 49 CFR Part 40.25(j) the employer is required to ask the employee:Have you ever 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 past two years?YesNoPREVIOUS ADDRESSES FOR THE PAST 3 YEARSAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country CURRENT DRIVERS LICENSEStateLicense No.Class/TypeExpiration DateDRIVER LICENSES FOR THE PAST 3 YEARSStateLicense No.Class/TypeExpiration DateDRIVER LICENSES FOR THE PAST 3 YEARSStateLicense No.Class/TypeExpiration DateHave you ever had your license, permit or driving privileges suspended or revoked?YesNoIf yes, list date & please explain:DRIVING EXPERIENCEVehicle TypeClass A (Semi-Tractors)List # of Years & Months Operated Class B (Straight Trucks/Dump Trucks, Etc.)List # of Years & Months Operated Class B (Buses/Passenger Vehicles)List # of Years & Months Operated Types of Trailers Transported/Operated Dry Van Reefer Flatbed Double/Triples Tanker Pneumatic Dump Trailer Hopper Intermodal Auto Hauler Specialized Hot Shot OtherIf Other, Please List:MOTOR VEHICLE ACCIDENTS FOR PAST 3 YEARS IF NONE, WRITE THE WORD “NONE”DateDescription of AccidentTowed Yes/No# of Fatalities# of InjuriesMOTOR VEHICLE ACCIDENTS FOR PAST 3 YEARS IF NONE, WRITE THE WORD “NONE”DateDescription of AccidentTowed Yes/No# of Fatalities# of InjuriesMOTOR VEHICLE ACCIDENTS FOR PAST 3 YEARS IF NONE, WRITE THE WORD “NONE”DateDescription of AccidentTowed Yes/No# of Fatalities# of InjuriesVIOLATIONS OF MOTOR VEHICLE LAWS or ORDINANCES FOR THE PAST 3 YEARS OTHER THAN PARKING VIOLATIONS - IF NONE, WRITE THE WORD “NONE”ViolationDate of Violation Date Format: MM slash DD slash YYYY ViolationDate of Violation Date Format: MM slash DD slash YYYY ViolationDate of Violation Date Format: MM slash DD slash YYYY ViolationDate of Violation Date Format: MM slash DD slash YYYY ViolationDate of Violation Date Format: MM slash DD slash YYYY ViolationDate of Violation Date Format: MM slash DD slash YYYY ViolationDate of Violation Date Format: MM slash DD slash YYYY Have you ever been convicted of a Felony?YesNoIf yes, list date & please explain:Have you ever been convicted of driving while intoxicated or under the influence of drugs or alcohol?YesNoIf yes, list date & please explain:Have you failed any DOT required alcohol and/or drug testing within the past 5 years?YesNoIf yes, list date & please explain:Past Employment or Lease Record (List ALL past employment and leasing for the past 10 years)Past Employer/Leased CompanyAddressCityStatePhone NumberFax NumberPosition HeldFrom Date Format: MM slash DD slash YYYY To Date Format: MM slash DD slash YYYY Reasons for LeavingWas your job subject to DOT alcohol and drug testing as required by 49 CFR Part 40?YesNoWere you subject to the FMCSR’s while employed/leased by this company?YesNoPast Employer/Leased CompanyAddressCityStatePhone NumberFax NumberPosition HeldFrom Date Format: MM slash DD slash YYYY To Date Format: MM slash DD slash YYYY Reasons for LeavingWas your job subject to DOT alcohol and drug testing as required by 49 CFR Part 40?YesNoWere you subject to the FMCSR’s while employed/leased by this company?YesNoPast Employer/Leased CompanyAddressCityStatePhone NumberFax NumberPosition HeldFrom Date Format: MM slash DD slash YYYY To Date Format: MM slash DD slash YYYY Reasons for LeavingWas your job subject to DOT alcohol and drug testing as required by 49 CFR Part 40?YesNoWere you subject to the FMCSR’s while employed/leased by this company?YesNoPast Employer/Leased CompanyAddressCityStatePhone NumberFax NumberPosition HeldFrom Date Format: MM slash DD slash YYYY To Date Format: MM slash DD slash YYYY Reasons for LeavingWas your job subject to DOT alcohol and drug testing as required by 49 CFR Part 40?YesNoWere you subject to the FMCSR’s while employed/leased by this company?YesNoPast Employer/Leased CompanyAddressCityStatePhone NumberFax NumberPosition HeldFrom Date Format: MM slash DD slash YYYY To Date Format: MM slash DD slash YYYY Reasons for LeavingWas your job subject to DOT alcohol and drug testing as required by 49 CFR Part 40?YesNoWere you subject to the FMCSR’s while employed/leased by this company?YesNoPast Employer/Leased CompanyAddressCityStatePhone NumberFax NumberPosition HeldFrom Date Format: MM slash DD slash YYYY To Date Format: MM slash DD slash YYYY Reasons for LeavingWas your job subject to DOT alcohol and drug testing as required by 49 CFR Part 40?YesNoWere you subject to the FMCSR’s while employed/leased by this company?YesNoPast Employer/Leased CompanyAddressCityStatePhone NumberFax NumberPosition HeldFrom Date Format: MM slash DD slash YYYY To Date Format: MM slash DD slash YYYY Reasons for LeavingWas your job subject to DOT alcohol and drug testing as required by 49 CFR Part 40?YesNoWere you subject to the FMCSR’s while employed/leased by this company?YesNoIn Case of Emergency Please Contact:NameRelationshipTelephone No.TO BE READ AND SIGNED BY THE APPLICANT This certifies that this application and any additional past employer records have been completed by me, and that all entries on it and information in it are true and complete to the best of my knowledge. I understand that if employed or leased, any misstatement or omission of fact on this application shall be considered cause for dismissal. I authorize investigation of all statements contained in this application for employment or lease as may be necessary in arriving at a decision.Applicant's SignatureDate of Application Date Format: MM slash DD slash YYYY NOTICE TO DRIVER APPLICANTS: Please complete the following pages for required verification and background checks. You must sign and complete all areas…. ALL DRIVER APPLICANTS MUST SIGN THE FOLLOWING ‘ PAST EMPLOYMENT SAFETY HISTORY REQUEST FORM ’. DO NOT COMPLETE THE ENTIRE FORM – SIGN AND DATE ONLY AT THE ARROW POINTING TO APPLICANTS SIGNATUREALL DRIVER APPLICANTS MUST READ AND SIGN THE FOLLOWING ‘ IMPORTANT NOTICE REGARDING BACKGROUND REPORTS FROM THE PSP Online Service ’.ALL DRIVER APPLICANTS MUST READ AND SIGN THE FOLLOWING ‘ HireRight DAC Trucking DOT D/A Disclosure and Authorization and Authorization for Disclosure of Information PAST EMPLOYMENT SAFETY HISTORY REQUEST FROM: Volusia County Towing, 345 8th Street, Holly Hill, FL 32117 PHONE: 386-872-7200 Please return by faxing to: 386-239-8607 Att: Hiring Manager This person named herein has applied to Volusia County Towing for employment in a safety-sensitive position.Name of Applicant:Social Security Number:I, the listed applicant, hereby authorize the following company(s) to release all records of employment, including assessments of my job performance, ability, fitness and drug testing results to Volusia County Towing. I hereby release the below listed company(s), and its employees, officers, directors, and agents from any and all liability of any type as a result of providing the following information to the above-mentioned company. The applicant’s signature on this form releases all liability of you and your company. Information is being requested in accordance with 49 CFR Parts 40, 382 and 391.Past Employer's Name:Past Employer's Address:Past Employer's Fax #:Applicant's SignatureDate Date Format: MM slash DD slash YYYY To be completed by past employer: Dates of Employment:From: Date Format: MM slash DD slash YYYY To: Date Format: MM slash DD slash YYYY HoursFull TimePart-TimePosition(s) Held:Local:Regional:Over-the-Road:Did this driver operate commercial motor vehicles greater than 26,000 lbs GVWR?YesNoType of equipment operated:Dry VanFlatbedReeferReasons for leaving:VoluntaryLay-offTerminatedRetiredIf terminated, why?Eligible for rehire?YesNoUpon ReviewNo, Company PolicyCompany Policy:Motor Vehicle Accident/Equipment Damage/Incident Inquiry, If no accidents please check box - None Yes NoneAccident Date Date Format: MM slash DD slash YYYY City, StateDid the Accident Involve? Tow Injury Fatality HM ReleaseBrief DescriptionAccident Date Date Format: MM slash DD slash YYYY City, StateDid the Accident Involve? Tow Injury Fatality HM ReleaseBrief DescriptionAccident Date Date Format: MM slash DD slash YYYY City, StateDid the Accident Involve? Tow Injury Fatality HM ReleaseBrief DescriptionAccident Date Date Format: MM slash DD slash YYYY City, StateDid the Accident Involve? Tow Injury Fatality HM ReleaseBrief DescriptionAlcohol & Controlled Substance Testing InquiryHas this driver ever had a breath alcohol test within the past 3 years a result of 0.04 or higher alcohol concentration?YesNoHas this driver ever had a positive drug test in the past 3 years?YesNoHas this driver refused a controlled substance test and/or alcohol test within the past 3 years?YesNoHas this driver violated any other DOT drug/alcohol regulation?YesNoTo your knowledge has this driver violated any DOT drug and alcohol regulations at a previous employer?YesNo**If the answer to any of the above questions is “Yes”, please provide details belowReason for test(s): Result of test(s): Date of test(s):If the applicant tested positive, to your knowledge, have they satisfactorily completed all return to duty and follow-up testing requirements in accordance 49 CFR 382.503?YesNoAny other remarks (including SAP name and address):Information provided by (name & job title)Date Date Format: MM slash DD slash YYYY First Request Date Date Format: MM slash DD slash YYYY Contact TypeFaxMailPhoneAttempt Made By:Second Request Date Date Format: MM slash DD slash YYYY Contact TypeFaxMailPhoneAttempt Made By:Third Request Date Date Format: MM slash DD slash YYYY Contact TypeFaxMailPhoneAttempt Made By:Authorization for Disclosure of Information I hereby authorize all of the following, without limitation, to disclose information about me to a consumer-reporting agency such as HireRight, Inc. (“HireRight”), and its agents in connection with its preparation of background reports on me for Zenith Freight Lines, LLC (the “Company”) Law enforcement and all other federal, state and local agencies;Learning institutions (including public and private schools, colleges and universities);Testing agencies;Information service bureaus;Credit bureaus;Record/data repositories;Courts (federal, state, and local);Motor vehicle records agencies;My past or present employers;The military; andAll other individuals and sources with any information about or concerning me. The information that can be disclosed to the consumer reporting agency and its agents includes, but is not limited to, information concerning my employment and earnings history, education, credit history, motor vehicle history, criminal history, military service, professional credentials and licenses. Applicant Name:* First Middle Last Applicant Signature*Date* Date Format: MM slash DD slash YYYY IDENTIFYING INFORMATION FOR CONSUMER REPORTING AGENCY (Complete Entire Section)Applicant Name: First Middle Last Other Names Used:Years Used:Current Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Former Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code *Social Security NumberDaytime Phone NumberDrivers License NumberState*Date of Birth Date Format: MM slash DD slash YYYY *GenderEmail Address *This information will be used only for background screening purposes and will not be taken into consideration in any employment decisions.THE BELOW DISCLOSURE AND AUTHORIZATION LANGUAGE IS FOR MANDATORY USE BY ALL ACCOUNT HOLDERS IMPORTANT DISCLOSURE REGARDING BACKGROUND REPORTS FROM THE PSP Online Service In connection with your application for employment with Volusia County Towing (“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 Volusia County Towing (“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. Signature*Date* Date Format: MM slash DD slash YYYY Name (Please Print)* First Last NOTICE: 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. LAST UPDATED 12/22/2015CommentsThis field is for validation purposes and should be left unchanged.