List your address(es) of residency for the past three years. No P.O. Boxes.
All driver applicants must provide information on all employers during the preceding three years. Applicants for commercial motor vehicle positions must also provide an additional seven years of information. List employers in reverse order starting with the most recent. Complete mailing addresses, street number, city, state, zip code and phone number are required.
List information regarding your driving experience. If no experience, write "None."
List all traffic convictions and forfeitures. Do not include parking violations.
Federal Motor Carrier Safety Regulations require a list of all motor vehicle accidents in which the applicant was involved during the three years preceding this application. (FMCSR 391.21(b)(7))
This authorization allows Delta Waste Solutions to contact your previous employers as required by Section 391.23 and Section 383.35 of the Federal Motor Carrier Safety Regulations.
I hereby authorize you to release the following information to Delta Waste Solutions LLC for the purposes of investigation as required by section 391.23 and allowed by Section 383.35 of the Federal Motor Carrier Safety Regulations. You are released from any and all liability which may result from furnishing such information.
In connection with your application for employment with Delta Waste Solutions LLC, the company may obtain one or more reports regarding your driving and safety inspection history from the Federal Motor Carrier Safety Administration (FMCSA).
If the company uses any information it obtains from FMCSA in a decision to not hire you or to make any other adverse employment decision, the company 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.
Driver Requirements: Parts 383 and 391 of the Federal Motor Carrier Safety Regulations require the following:
1) Possess Only One License: You may not possess more than one motor vehicle operator's license. If you have more than one, keep the one from your state of residence and return all others.
2) Notification of License Suspension, Revocation, or Cancellation: You must notify your employer the next business day of any revocation or suspension of your driver's license. Additionally, any time you violate a state or local traffic law (other than parking), you must report it within 30 days to your employer and the state that issued your license.
I certify that I have read and understand the above requirements. The license listed above is the only one I will possess.
Delta Waste Solutions LLC has provided me with a copy of their Controlled Substances and Alcohol Testing Policy. By my signature, I acknowledge that I have read and understand this policy.
The following information is required by the Federal Motor Carrier Regulations, Section 40.25. Have you tested positive, or refused to test, on any pre-employment drug or alcohol test administered by an employer to which you applied for, but did not obtain, safety sensitive transportation work covered by DOT agency drug and alcohol testing rules during the past two (2) years?
For first time or intermittent drivers. Provide total time on duty (driving and on duty) during the immediate preceding seven days and the time at which you were last relieved from duty.
I hereby certify that the information provided above is true and correct to the best of my knowledge and belief, and that I was last relieved from work at:
Beginning May 21, 2014, motor carriers must verify that the medical examiner who signed the driver's medical card is listed on the National Registry of Certified Medical Examiners. This requirement is prescribed in §391.23 and §391.51.
Delta Waste Solutions LLC has provided me with a copy of their Cell Phone Policy. By my signature, I acknowledge that I have read and understand this policy. CMV drivers may not use hand-held mobile phones while driving. Texting is strictly prohibited at all times while operating a CMV (49 CFR Part 392.80). Violations may result in disciplinary action, up to and including termination.
I hereby provide consent for Delta Waste Solutions LLC to conduct a limited query of the FMCSA Commercial Driver's License Drug and Alcohol Clearinghouse (Clearinghouse) to determine whether drug or alcohol violation information about me exists in the Clearinghouse.
I understand that if I refuse to provide consent, Delta Waste Solutions LLC must prohibit me from performing safety-sensitive functions, including driving a commercial motor vehicle.
This consent to conduct a limited query shall be active for the duration of my employment with Delta Waste Solutions LLC.
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 Delta Waste Solutions 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
If you agree that the Prospective Employer may obtain such background reports, please read the following and sign below:
I authorize Delta Waste Solutions LLC (“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.
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 2/11/2016
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. I authorize Delta Waste Solutions LLC to inquire of personal, employment, financial, medical and other related matters as may be necessary in arriving at employment decisions. I hereby release employers, schools, health care providers and other personnel from all liability in response to and release of information regarding my application. In the event of employment, I understand that false and/or misleading information given in my application or interview may result in discharge. I understand 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 employers will be contacted, for the purpose of investigating my safety performance history as required by 49CFR391.23(d) and (e).