FAIR CREDIT REPORTING ACT DISCLOSURE STATEMENT
In accordance with the provisions of the Fair Credit Reporting Act (Public La 91-508) as amended by the Consumer Credit
Reporting Act of 1996. I have been informed the Company will procure a motor vehicle report (MVR), criminal
background check and reference checks, all of which are defined as a consumer report regarding my driving and
background record to determine my suitability for work at the Company.
I understand that I have the right to request, in writing, information pertaining to the nature and scope of the inquiry and
a written summary of my rights under the Fair Credit Reporting Act. I understand that I may have additional rights under
applicable state and federal laws.
I hereby authorize the Company to obtain this information and release and hold harmless any person, firm, or entity that
discloses such information in accordance with this authorization. This authorization shall remain on file and shall serve as
ongoing authorization for the Company to procure a motor vehicle report (MVR) and a criminal check which is defined as a
consumer report at any time during my employment period. Any copy of this authorization shall have the same authority
as the original.
I CERTIFY THAT ALL ANSWERS GIVEN BY ME ARE TRUE, ACCURATE AND COMPLETE, I UNDERSTAND THAT THE
FALSIFICATION, MISREPRESENTATION OR OMISSION OF FACT ON THIS EMPLOYMENT APPLICATION (OR ANY OTHER
ACCOMPANYING OR REQUIRED DOCUMENTS) MAY RESULT IN MY NOT BEING CONSIDERED FOR EMPLOYMENT, AND
IF NOT DISCOVERED BY THE COMPANY UNTIL AFTER BECOMING EMPLOYED, IS GROUNDS FOR, AND MAY RESULT IN
Questions regarding this statement should be directed to any employment interviewer before signing. The application will
be given every consideration, but its receipt does not imply that the applicant will be employed.
To the extent not otherwise prohibited by FMCSA regulation or any other applicable regulations or laws, it is the policy of
the company to provide equal employment opportunities to all individuals, regardless of race, color, creed national origin,
ethnicity, ancestry, sex, sexual orientation or preference, age, religious beliefs, disability, genetic information, citizenship
status, pregnancy, child bearing status, marital status, veteran status, military service, or any other characteristic protected
by applicable law.
I authorize the investigation of all statements and information contained in this application. I release from all liability
anyone supplying such information and I also release the Employer from all liability that might result from making an
I hereby understand and acknowledge that, unless otherwise defined by applicable law, any employment relationship with
this organization is of an "at will" nature, which means that the Employee may resign at any time and the Employer may
discharge Employee at any time with or without cause. It is further understood that this "at will" employment relationship
may not be changed by any written documentation or by conduct unless an authorized executive of this organization
specifically acknowledges such change in writing.
PRE-EMPLOYMENT SCREENING NOTICE - CONTINUED
If hired, I agree to abide by all of the company rules and regulations. I further understand that no representation, whether
oral or written by any representative or agent of the Company, at any time, can constitute a contract of employment. I
understand that the Company shall have the maximum discretion permitted by law to administer, interpret, modify,
discontinue, enhance or otherwise change all policies, procedures, benefits or other terms or conditions of employment. No
representative or agent of the company, has the authority to enter into any agreement for employment for any specified
period of time or to make any change in any policy, procedure, benefit or other term or condition of employment other
than in a document signed by a Managing Member or to make any agreement contrary to the foregoing.
I understand that my employment with the company shall be probationary for a period of six months and further that at
any time during the probationary period or thereafter, my employment relationship with the company may be
terminated without right of appeal.
I understand that if employed on a temporary basis, I would be paid for hours, worked only, and would be ineligible for
benefits including paid time off. If employed on a regular, benefits-eligible basis, I understand that any benefits I receive
may be subject to change or discontinuation at any time without prior notice.
NOTIFICATION AND AGREEMENT
The Company may not require a pre-employment medical examination, but does reserve the right to require drug testing
and a medical examination after an offer of employment is made to the applicant. All offers of employment are conditional
upon the passing of a drug test for the purpose of detecting the illegal use of drugs. Also, if an employment offer is made,
you will be asked to answer certain medical questions. Medical examinations and answers to medical inquiries will be
maintained on separate forms, and will be treated as confidential medical records. An applicant will not be excluded from
employment unless they have medical conditions that prohibit their ability to perform the essential job functions of the
position they desire within this company. The Company will make reasonable accommodations to qualified individuals with
disabilities in the application process and, if hired, allow qualified individuals with disabilities to perform essential job
functions. Written job descriptions are available and will be furnished to applicants upon request.
The Company may use the information contained in this application and may contact your former employer(s) for the
purpose of investigating yoursafety performance history information as required by the Federal Motor Safety Regulations
(49 CFR 391.23 (d) and (3). Pursuant to 49 CFR 391.23 (i), you have the following rights regarding the investigative
information that is provided to The Company by your previous employer(s):
- You have the right to review the information provided by your previous employer(s);
- You have the right to have errors in the information corrected by your previous employer(s) and for the previous
employer(s) to re-send the corrected information to The Company; and
- You have the right to have a rebuttal statement attached to the alleged erroneous information, if you and
your previous employer cannot agree on the accuracy of the information
Carefully review the following conditions. If you have any questions regarding the conditions, you should ask for an
explanation or clarification from the employment interviewer. Signify your understanding and specific acceptance of each
condition by your signature in the space provided at the end of the conditions.
hereby authorize The Company to investigate any and all statements contained in this application. I hereby consent to The
Company conducting any checks concerning my background which are deemed necessary, advisable, or helpful by The
Company (except contacting my current employer prior to hiring, unless permission is granted above). I understand that if
hired, I will receive a copy of The Company rules and regulations and the Company's policies including its drug/alcohol
policy. I will read and understand the rules, regulations, and policies; and I acknowledge that I will be required to abide by
them. I understand that if hired, I will be required to submit to a drug test as part of this application procedure. I hereby
consent to that drug test, agree to cooperate fully with that drug test, and waive any and all objections I might otherwise
have to such drug testing. I understand that if I am offered employment, it may be contingent upon passing a medical
examination. If so, I hereby consent to such medical examination, and will fully cooperate with any required examination. I
understand and agree that if this application results in employment, my employment can be terminated with or without
cause and with or without notice, at any time, at the option of either The Company or myself. I understand that no
manager or representative of The Company as any authority to enter into any agreement for employment for any specified
period of time or to make any agreement contrary to the foregoing.
I certify and guarantee that all statements made on this application are true and complete to the best of my knowledge and
without mental reservations. I understand that falsification of this application may result in my not being considered for
employment or, in the event I become employed by The Company in my dismissal, regardless of when such falsification is
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.