I have read and understood the preceding Disclosure to Consumer. Under the Fair Credit Reporting Act (“FCRA”), 15 U.S.C. § 1681 et seq., the regulations applicable to the federal Department of Transportation’s Federal Motor Carriers Safety Administration, including 49 CFR § 40.329, the Americans with Disabilities Act and all other applicable federal, state, and local laws, I hereby authorize and permit the above named company to obtain information about me, where permitted, which may pertain to my employment records, driving history records, driving performance and safety history, criminal history, credit history, civil records, workers’ compensation (post-offer only), alcohol and drug testing, verification of my academic and/or professional credentials, and information and/or copies of documents from any military service records.
I understand an “investigative consumer report” may include information as to my character, general reputation, personal characteristics, and mode of living that may be obtained by interviews with individuals who may have knowledge concerning any such items of information. I authorize information to be obtained from my former employers to satisfy driver qualification regulations.
DOT Drivers. I understand that Title 49 of the Federal Code of Regulations, § 391.23, requires that my prospective employer and/or its agent(s) may contact all former employers of a driver within the last three years under the regulation of the Department of Transportation. Information such as dates of employment, position, accident history, as well as information pertaining to my drug and alcohol testing history, may be requested from each employer in accordance with Section 391.23 and 49 CFR 40.25.
By signing below, I consent to and authorize the gathering of this information by my prospective employer or employer and those who my prospective employer or employer has engaged to request and obtain this information including former employers, and/or from or through a consumer reporting agency, such as iiX, a Verisk Analytics Business.
I understand and acknowledge that the information provided in the consumer reports or investigative consumer reports may assist my employer or prospective employer to make a determination regarding my suitability as an employee.
I further understand that, under the FCRA, in the event of Adverse Action, I may request a copy of any consumer report from the consumer reporting agency that compiled the report, after I have provided proper identification.
I agree that a copy of this authorization has the same effect as an original. Where permitted, this authorization shall remain in effect over the course of my employment and reports may be ordered periodically during the course of my employment.
EQUAL EMPLOYMENT OPPORTUNITY (EEO) & SECTION EMPLOYER SELF-IDENTIFICATION FORM
Qualified applicants are considered for employment without regard to race, religion, sex, national origin, age, marital status, sexual orientation, veteran status, disability, or other protected characteristic.
PLEASE READ ALL INSTRUCTIONS CAREFULLY BEFORE COMPLETING THIS FORM
This employer is subject to certain nondiscrimination and affirmative action recordkeeping and reporting requirements which require the employer to invite employees to voluntarily self-identify their gender, race/ethnicity and disability status. Submission of this information is voluntary and refusal to provide it will not subject you to any adverse treatment. This information will be kept confidential and may only be used in accordance with the provisions of applicable federal laws, executive orders, and regulations, including those which require the information to be summarized and reported to the Federal Government for civil rights enforcement purposes. If you choose not to self-identify at this time, the federal government requires this employer to determine this information by visual survey and/or other available information.
This form will be kept in a confidential file separate from your application for employment.
Voluntary Self-Identification of Disability
Why are you being asked to complete this form?
Because we do business with the government, we must reach out to, hire, and provide equal opportunity to qualified people with disabilities. To help us measure how well we are doing, we are asking you to tell us if you have a disability or if you ever had a disability. Completing this form is voluntary, but we hope that you will choose to fill it out. If you are applying for a job, any answer you give will be kept private and will not be used against you in any way.
If you already work for us, your answer will not be used against you in any way. Because a person may become disabled at any time, we are required to ask all of our employees to update their information every five years. You may voluntarily self-identify as having a disability on this form without fear of any punishment because you did not identify as having a disability earlier.
How do I know if I have a disability?
You are considered to have a disability if you have a physical or mental impairment or medical condition that substantially limits a major life activity, or if you have a history or record of such an impairment or medical condition.
Disabilities include, but are not limited to:
- Blindness
- Deafness
- Cancer
- Diabetes
- Epilepsy
- Autism
- Cerebral palsy
- HIV/AIDS
- Schizophrenia
- Muscular dystrophy
- Bipolar disorder
- Major depression
- Multiple sclerosis (MS)
- Missing limbs or partially missing limbs
- Post-traumatic stress disorder (PTSD)
- Obsessive compulsive disorder
- Impairments requiring the use of a wheelchair
- Intellectual disability (previously called mental retardation)
I understand and agree:
1. Any material misrepresentation or deliberate omission of any fact in my application may be justified for refusal of, or if employed, termination from employment.
2. It is my understanding that the company will make a thorough investigation of my entire work and personal history and may verify all data given in my application for employment, related papers, or oral interviews. I authorize such investigation and the giving and receiving of any information requested by the company and I release from liability any person giving or receiving any such information. I understand that falsification of data so given or other derogatory information discovered as a result of this investigation may prevent my being hired, or if hired, may subject me to immediate dismissal.
3. I agree that my employment may be terminated by this company at any time without liability for wages or salary except such as may have been earned at the date of such termination. If requested by the management at any time, I agree to submit to search of my personals or of any locker that may be assigned to me, and I hereby waive all claims for damages on account of such examination. I authorize any physician or hospital to release any information which may be necessary to determine my ability to perform the duties of a job I am being considered for prior to my employment or in the future during my employment with the company.
4. Although management makes every effort to accommodate individual preferences, business needs may at times make the following conditions mandatory: overtime, shift work, a rotating work schedule, or a work schedule other than Monday through Friday. I understand and accept these as conditions of my continuing employment.
I further understand that this is an application for employment and that no employment contract is being offered.
I understand that if I am employed, such employment is an indefinite period of time and that the company can change wages, benefits, and conditions at any time.
I have read and understand the above.
