fc362c9fb84a420fbc44a59736c9820a-381x191.dm.edit_SsD1KE-472w

APPLICATION FOR EMPLOYMENT

COMMERCIAL DRIVER

COYLE TRUCKING, INC. / COYLE TRANSPORT SERVICES, INC.
260 Route 519 Eighty Four, PA 15330
800-811-0947 FAX: 724-222-2450

"*" indicates required fields

Step 1 of 11

Experience And Qualifications - Driver
List All Driver Licenses*
State
License No.
Type (A,B, etc.)
Expiration Date

Endorsements:

Driving Experience - Class of Equipment
Straight Truck
Type of Equipment (van, tank, flat, etc.)
Approximate Miles (total)
From Date
To Date

TRACTOR AND SEMI-TRAILER
Type of Equipment (van, tank, flat, etc.)
Approximate Miles (total)
From Date
To Date

TRACTOR-TWO TRAILERS
Type of Equipment (van, tank, flat, etc.)
Approximate Miles (total)
From Date
To Date

Other
Type of Equipment (van, tank, flat, etc.)
Approximate Miles (total)
From Date
To Date

Driving Record

Accident record for past five years or more
Date of Last Accident
Nature of Accident (head-on, rear-end, upset, etc.)
Fatalities? (yes or no)
Injuries? (yes or no)

Hours of service violations, traffic convictions and forfeitures for the past five years
Location
Date
Charge
Penalty

Education
Highest Level Completed*

1

2

3

4

5

6

7

8
High School*

1

2

3

4

None
College*

1

2

3

4

None
Name of Last School Attended*

Other Experience and Qualifications
List courses and training other than those shown elsewhere in this application:
Consent*
This certifies that I completed this application, and that all entries on it and information in it are true and complete to the best of my knowledge.
Disclosure:
A consumer report and a criminal background report may be procured by Coyle Trucking, Inc./ Coyle Transport Services, Inc. as part of your application for employment and to periodically obtain updated reports.

As required by the Fair Credit Reporting Act (the FCRA), this disclosure is to inform you that a consumer report, including information as to the character, general reputation, personal characteristics, and mode of living, whichever are applicable, may be procured from time to time. Such reports may contain public information concerning your driving record, safety record, workers' compensation claims, credit, bankruptcy proceedings, criminal records, etc. from federal, state and other agencies, which maintain such records.

Authorization:
This signed Authorization is my authorization and consent for the Company to procure consumer and criminal background reports, from time to time as required by the Company for employment purposes. I understand and agree that I am subject to a consumer and criminal background report to determine my eligibility, and continued eligibility, for employment and I specifically authorize the release, without any liability to the Company whatsoever, of any findings for those purposes only. These reports may include: previous employer verifications, reason for termination, accidents, driving records, workers compensation claims, etc. I further understand that such reports may contain information from federal, state or other agencies. I hereby release employers, schools, healthcare providers and other persons from all liability in responding to inquiries and releasing information in connection with my application. You have to review information provided to us by your previous employers and have any errors in such information corrected by your previous employer as stated in section 391.23 (i) of the FMCSRs. Should you wish to review this information you must submit a written request to us, your prospective employer, as stated in section 391.23 (i) of the FMCSRs.

I acknowledge and confirm that obtaining the reports and information are reasonable and necessary in order to determine my qualifications and competency for employment. This authorization shall remain on file and shall serve as on-going authorization for the Company to procure consumer and criminal background reports, at any time during my employment and the qualification process with respect thereto. I understand that, upon termination of my employment for any reason, this authorization will have no further effect. To obtain a copy of the Fair Credit Reporting Act Summary of Rights Notice, you may visit the website at:
www.consumerfinance.gov/learnmore.

I authorize, per 49 CFR Part 40 of FMCSRs, the release of information from my DOT regulated drug and alcohol testing records by my previous employers. I authorize the release of the following information concerning DOT drug and alcohol testing violations including pre-employment tests during the past three years: (i) alcohol tests with a result of 0.04 or higher; (ii) verified positive drug tests; (iii) refusals to be tested (including verified adulterated or substituted results); (iv) other violations of DOT drug and alcohol testing regulations; (v) information obtained from previous employers of drug and alcohol rule violation(s); and (vi) documents, if any, of completion of return-toduty process following a rule violation.

I hereby certify that I have read the foregoing and understanding the contents of this Disclosure and Authorization. I also understand the remedies available to me should I disagree with the Consumer Reporting Agency with respect to the consumer report.
Applicant's Signature*
Date
MM slash DD slash YYYY

List All Unemployment / Self Employment Periods
Dates
Unemployed or Self-Employed
What was applicant doing during this time?

Personal & Confidential Medical Review Questionnaire Commercial Drivers
This information is requested to ensure that you can safely perform the essential functions of the job and that you meet all applicable federal regulations governing physical qualifications of commercial drivers. The information you provide below is considered personal, confidential and medical in nature and will be treated as such by handling it confidentially.
Have you had any on-the-job injuries?*

Yes

No
Complete for each injury*
Date of injury
Employer at the time
Cause of injury
How much time off work
Body part involved
% of impairment if applicable

Do you have or have you ever had any other injuries or illnesses, not on the job, which resulted in surgery, lost time from work, or hospitalization?*

Yes

No
Complete for each injury*
Date of injury/illness
Cause
Body part involved
How much time off work
Continuing treatment at this time

Are you currently taking any prescribed medications?*

Yes

No
Please List*
What medications are you currently taking
For what condition are you taking medication
Side effects to taking the medication

Do you currently have any medical restrictions or medical conditions that must be considered with your application pursuant to the Federal Motor Carrier Safety Regulations, 49 C.F. R §391 .41? (i.e. current diagnosis of myocardial infarction, diabetes requiring insulin for control, seizures, allergic reactions, hearing loss, etc)*

Yes

No
If yes, please explain:*

Are you currently under a doctor or chiropractor's care?*

Yes

No
If yes, please explain (including type of treatment and current restrictions:*

Have you ever had any problems affecting your wrists, back, neck, shoulders or knees that would affect your ability to perform the duties of the position with or without reasonable accommodations?*

Yes

No
If yes, please explain:*

Consent
I hereby certify that the information contained on this form is true and correct and that there are no omissions. I authorize any physician, medical facility, and/or past employers to furnish or verify workers' compensation and medical information.
Signature*
Date*
MM slash DD slash YYYY

Essential job functions worksheet commercial truckdriver (Class A & B)
The following are physical requirements pertaining to the job(s) for which you are applying. These bona find physical requirements are essential functions of the job and are in addition to the skill, certification, years of experience and other qualifications required to perform the job(s) for which you have applied. Please be aware that all persons may be required to furnish health condition information and if necessary, submit to an examination by a company-designated physician. This information will be used to determine appropriate job placement. It shall not be used to disqualify an otherwise qualified person who may have a mental or physical disability who can perform these essential functions with or without reasonable accommodations.

These statements/questions pertain only to the essential functions of the job for which you are applying.
Can you sit and drive as is required for an 11-hour shift?*

Yes

No
Please explain*
Can you perform repetitive motion tasks with your hands and wrists?*

Yes

No
Please explain*
Can you push and pull levers or objects that require 100 lbs. of force or more?*

Yes

No
Please explain*
Do you have free and continual movement of your legs and feet as required to safely operate a clutch, brake and gas pedal or foot controls of a truck?*

Yes

No
Please explain*
If required, are you able to reach and lift 60 lbs. above your head?*

Yes

No
Please explain*
Can you climb stairs safely to get in and out of a truck or with a load regularly?*

Yes

No
Please explain*
Can you grip, grasp and twist using your hands and wrists constantly as is required to safely operate the steering, shifting or other mechanical or hydraulic controls of a truck?*

Yes

No
Please explain*
If required, are you able to lift and move 100 lbs. or more?*

Yes

No
Please explain*
is there any reason you may not be considered physically qualified to operate a commercial motor vehicle per the qualifications set for in part §391.41 of the Federal Motor Carrier Safety Regulations?*

Yes

No
Please explain*
Signature*
Date*
MM slash DD slash YYYY

Consent*
I understand that in the event of any work related injury that I will be subject to a drug and alcohol test.

Refusal to do so may lead to denial of benefits under Workers'Compensation. I also understand that in the event of apositive result, benefits may also be denied.
Signature*
Date*
MM slash DD slash YYYY

The below disclosure and authorization language is for mandatory use by all account holders
Important disclosure regarding background reports from the PSP Online Services.
Consent*
I agree
In connection with your application for employment with Coyle Transport Services, inc / Coyle Trucking Inc. (“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 Coyle Transport Services, inc / Coyle Trucking Inc. (“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*
MM slash DD slash YYYY

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.

Motor vehicle certification of violations and annual review of driving record
MOTOR CARRIER INSTRUCTIONS: Each motor carrier shall at least once every 12 months, require each driver it employs to prepare and furnish it with a list of all violations of motor vehicle traffic laws and ordinances (other than violations involving only parking) of which the driver has been convicted, or on account of which he/she has forfeited bond or collateral during the preceding 12 months (Section 391.27).
Full Name (as shown on Driver's License)*

Social Security Number*

Date of Employment
MM slash DD slash YYYY

Driver's License Number*

Driver's License State*

License Expiration Date*
MM slash DD slash YYYY

Address*
Street Address City State ZIP Code

Consent*
I certify that the following is a true and complete list of traffic violations required to be listed for which I have been convicted or forfeited the past 12 months.
Have you had any violations?*

Yes

No
List all violations*
Date
Offense
Location
Type of Vehicle Operated

Consent*
If no violations are listed above, I certify that I have not been convicted or forfeited bond or collateral on account of any violation required to be listed during the past 12 months.
Date*
MM slash DD slash YYYY

Driver's signature*

BACKGROUND CHECK DISCLOSURE AND AUTHORIZATION FORM*
I have read
In the interest of maintaining the safety and security of our customers, employees and property, Coyle Trucking, Inc. (the "Company") will order a "consumer report" (a background report) or "investigative consumer report" on you in connection with your employment application, and if you are hired, or if you already work for the Company, may order additional background reports on you for employment purposes.

The background check company, HELPE, Inc., will prepare the background report for the Company. HELPE, Inc. is located at P.O. Box 1572, Camden, SC 29021 and can be reached by phone at 800-432-3934 or at their Internet Web site address www.helpe.com.

The background report may contain information concerning your character, general reputation, personal characteristics, mode of living, and credit standing. The types of information that may be ordered include but are not limited to: Social Security number verification; criminal, public, educational and, as appropriate, driving records checks; verification of prior employment; reference, licensing and certification checks; credit reports; drug testing results; and, if applicable, worker's compensation injuries. Workers' compensation information will only be requested in compliance with federal Americans with Disabilities Act and/or any other applicable federal, state or local laws and only after a conditional job offer is made. Credit history will only be requested when permitted by law and where such information is substantially related to the duties and responsibilities of the position for which you are applying. The information may be obtained from private and public record sources, including personal interviews with your associates, friends, and neighbors. (An "investigative consumer report" is a background report that includes information from such personal interviews, except in California where that term means any background report that is not a credit report.) The nature and scope of the most common form of investigative consumer report is an investigation into your education and/or employment history conducted by HELPE, Inc. or another outside organization.

You may request more information about the nature and scope of an investigative consumer report, if any, by telephoning the Company at 1-800-811-094 7. A summary of your rights under the Fair Credit Reporting Act is also being provided to you with this form.

The Fair Credit Reporting Act gives you specific rights in dealing with consumer reporting agencies. You will find these rights summarized on A Summary of Your Rights Under the Fair Credit Reporting Act and A Summary of Your Rights Under the Provisions of California Civil Code Section 1786.22 as provided here.

STATE LAW NOTICES

If ou live or work for the Com an in the states listed below, lease note the following:

Oregon If the Company obtains credit history information on you, it will be used to evaluate whether you would present an

WASHINGTON STATE: If you submit a request to us in writing, you have the right to get from the Company a complete and accurate disclosure of the nature and scope of the investigative consumer report we ordered, if any. You also have the right to ask ADP Screening and Selection Services for a written summary of your rights under the Washington Fair Credit Reporting Act. If the Company obtains information bearing on your credit worthiness, credit standing or credit capacity, it will be used to evaluate whether you would present an unacceptable risk of theft or other dishonest behavior in the job for which you are being considered.
AUTHORIZATION FOR BACKGROUND CHECKS*
I certify that all of the personal information I provided is true and correct.
Last Name*

First Name*

Middle Name*

Maiden / Other Names

Years Used

If you live or work for the Company in California, Minnesota or Oklahoma: Check this box if you would like a free copy of your background check report:

Yes

No
Signature*
Date*
MM slash DD slash YYYY

Background Check Information*
I consent
The information requested below is collected solely for the purpose of aiding the Company in running a background check in connection with your application for employment. The employer is requesting that you provide this information to assist in conducting a thorough background check.
For residents of, or for jobs located in Utah, please do NOT provide your date of birth, social security number or driver's license number until instructed to do so by the Company.
First Name*

Middle Name*

Last Name*

Date*
MM slash DD slash YYYY

Social Security*

Drivers License Number*

State Issuing License*

Enter Any Other Names Used (including maiden names):*
First Name
Middle Name
Last Name

Addresses Within The Past Seven Years*
Street Address City State ZIP Code

Consent*
I have read
Para informacion en espanol, visite
www.consumerfinance.gov/learnmore o escribe a la Consumer Financial Protection Bureau, 1700 G Street N.W., Washington, DC 20552.
A Summary of Your Rights Under the Fair Credit Reporting Act
The federal Fair Credit Reporting Act (FCRA) promotes the accuracy, fairness, and privacy of information in the files of consumer reporting agencies. There are many types of consumer reporting agencies, including credit bureaus and specialty agencies (such as agencies that sell information about check writing histories, medical records, and rental history records). Here is a summary of your major rights under the FCRA. For more information, including information about additional rights, go to www.consumerfinance.gov/learnmore or write to:
Consumer Financial Protection Bureau,
1700 G Street
N.W., Washington, DC 20552.

• You must be told if information in your file has been used against you. Anyone who uses a credit report or another type of consumer report to deny your application for credit, insurance, or employment - or to take another adverse action against you - must tell you, and must give you the name, address, and phone number of the agency that provided the information.
• You have the right to know what is in your file. You may request and obtain all the information about you in the files of a consumer reporting agency (your "file disclosure"). You will be required to provide proper identification, which may include your Social Security number. In many cases, the disclosure will be free. You are entitled to a free file disclosure if:

Para informacion en espanol, visite
www.consumerfinance.gov/learnmore o escribe a la Consumer Financial Protection Bureau, 1700 G Street N.W., Washington, DC 20552.
A Summary of Your Rights Under the Fair Credit Reporting Act
The federal Fair Credit Reporting Act (FCRA) promotes the accuracy, fairness, and privacy of information in the files of consumer reporting agencies. There are many types of consumer reporting agencies, including credit bureaus and specialty agencies (such as agencies that sell information about check writing histories, medical records, and rental history records). Here is a summary of your major rights under the FCRA. For more information, including information about additional rights, go to www.consumerfinance.gov/learnmore or write to:
Consumer Financial Protection Bureau,
1700 G Street
N.W., Washington, DC 20552.

You must be told if information in your file has been used against you. Anyone who uses a credit report or another type of consumer report to deny your application for credit, insurance, or employment - or to take another adverse action against you - must tell you, and must give you the name, address, and phone number of the agency that provided the information.

You have the right to know what is in your file. You may request and obtain all the information about you in the files of a consumer reporting agency (your "file disclosure"). You will be required to provide proper identification, which may include your Social Security number. In many cases, the disclosure will be free. You are entitled to a free file disclosure if:

a person has taken adverse action against you because of information in your credit report;

you are the victim of identity theft and place a fraud alert in your file;

your file contains inaccurate information as a result of fraud;

you are on public assistance;

you are unemployed but expect to apply for employment within 60 days.

In addition, all consumers are entitled to one free disclosure every 12 months upon request from each nationwide credit bureau and from nationwide specialty consumer reporting agencies. See www.consumerfinance.gov/learnmore for additional information.

You have the right to ask for a credit score. Credit scores are numerical summaries of your credit-worthiness based on information from credit bureaus. You may request a credit score from consumer reporting agencies that create scores or distribute scores used in residential real property loans, but you will have to pay for it. In some mortgage transactions, you will receive credit score information for free from the mortgage lender.

You have the right to dispute incomplete or inaccurate information. If you identify information in your file that is incomplete or inaccurate, and report it to the consumer reporting agency, the agency must investigate unless your dispute is frivolous. See
www.consumerfinance.gov/learnmore for an explanation of dispute procedures.

Consumer reporting agencies must correct or delete inaccurate, incomplete, or unverifiable information. Inaccurate, incomplete or unverifiable information must be removed or corrected, usually within 30 days. However, a consumer reporting agency may continue to report information it has verified as accurate.

Consumer reporting agencies may not report outdated negative information. In most cases, a consumer reporting agency may not report negative information that is more than seven years old, or bankruptcies that are more than 10 years old.

Access to your file is limited. A consumer reporting agency may provide information about you only to people with a valid need -- usually to consider an application with a creditor, insurer, employer, landlord, or other business. The FCRA specifies those with a valid need for access.

You must give your consent for reports to be provided to employers. A consumer reporting agency may not give out information about you to your employer, or a potential employer, without your written consent given to the employer. Written consent generally is not required in the trucking industry. For more information, go to
www.consumerfinance.gov/learnmore.

You may limit "prescreened" offers of credit and insurance you get based on information in your credit report. Unsolicited "prescreened" offers for credit and insurance must include a toll-free phone number you can call if you choose to remove your name and address from the lists these offers are based on. You may opt-out with the nationwide credit bureaus at 1-888-567-8688.

You may seek damages from violators. If a consumer reporting agency, or, in some cases, a user of consumer reports or a furnisher of information to a consumer reporting agency violates the FCRA, you may be able to sue in state or federal court.

Identity theft victims and active duty military personnel have additional rights. For more information, visitwww.consumerfinance.gov/learnmore.

States may enforce the FCRA, and many states have their own consumer reporting laws. In some cases, you may have more rights under state law. For more information, contact your state or local protection agency or your state Attorney General. For information about your federal rights, contact:

Type of Business

Banks, savings associations, and credit unions with total assets of over $10 billion and their affiliates.

Such affiliates that are not banks, savings associations, or credit unions also should list, in addition to the CFPB:

To the extent not included in item 1 above:

National banks, federal savings associations, and federal branches and federal agencies of foreign banks

State member banks, branches and agencies of foreign banks (other than federal branches, federal agencies, and Insured State Branches of Foreign Banks), commercial lending companies owned or controlled by foreign banks, and organizations operating under section 25 or 25A of the Federal Reserve Act

Nonmember Insured Banks, Insured State Branches of Foreign Banks, and insured state savings associations

Federal Credit Unions

Air carriers

Creditors Subject to the Surface Transportation Board

Creditors Subject to the Packers and Stockyards Act, 1921

Small Business Investment Companies

Brokers and Dealers

Federal Land Banks, Federal Land Bank Associations, Federal Intermediate Credit Banks, and Production Credit Associations

Retailers, Finance Companies, and All Other Creditors Not Listed Above

Contact

Consumer Financial Protection Bureau
1700 G Street, N.W.
Washington, DC 20552

Federal Trade Commission: Consumer Response Center- FCRA
Washington, DC 20580
(877) 382-4357

Office of the Comptroller of the Currency
Customer Assistance Group
1301 McKinney Street, Suite 3450
Houston, TX 77010-9050

Federal Reserve Consumer Help Center
P.O. Box 1200
Minneapolis, MN 55480

FDIC Consumer Response Center
1100 Walnut Street, Box # 11 Kansas City, MO 64106

National Credit Union Administration
Office of Consumer Protection (OCP)
Division of Consumer Compliance and Outreach (DCCO) 1775 Duke Street
Alexandria, VA 22314

Asst. General Counsel for Aviation Enforcement & Proceedings Aviation Consumer Protection Division
Department of Transportation
1200 New Jersey Avenue, S.E.
Washington, DC 20590

Office of Proceedings, Surface Transportation Board Department of Transportation
395 E Street, S.W.
Washington, DC 20423
Nearest Packers and Stockvards Administration area supervisor

Associate Deputy Administrator for Capital Access United States Small Business Administration 409 Third Street, SW, 8th Floor
Washington, DC 20416

Securities and Exchange Commission 100 F Street, N.E.
Washinaton, DC 20549

Farm Credit Administration
1501 Farm Credit Drive
McLean, VA 22102-5090

FTC Regional Office for region in which the creditor operates or Federal Trade Commission: Consumer Response Center- FCRA
Washington, DC 20580
(877) 382-4357

A Summary of Your Rights
Under the Provisions of California Civil Code Section 1786.22

The Investigative Consumer Reporting Agencies Act (ICRA) is designed to promote accuracy, fairness, and privacy of information in the files of every "consumer reporting agency" (CRA). You can find the complete text of the ICRA, at the California Privacy Protection web site (http://www.privacy.ca.gov/icraa.htm). The ICRA gives you specific rights, as outlined below. You may have additional rights under federal law. You may contact a state or local consumer protection agency or a state attorney general to learn those rights.

An investigative consumer reporting agency shall supply files and information required under Section 1786.10 during normal business hours and on reasonable notice.

Files maintained on a consumer shall be made available for the consumer's visual inspection, as follows:

In person, if he appears in person and furnishes proper identification. A copy of his file shall also be available to the consumer for a fee not to exceed the actual costs of duplication services provided.

By certified mail, if he makes a written request, with proper identification, for copies to be sent to a specified addressee. Investigative consumer reporting agencies complying with requests for certified mailings under this section shall not be liable for disclosures to third parties caused by mishandling of mail after such mailings leave the investigative consumer reporting agencies.

A summary of all information contained in files on a consumer and required to be provided by Section 1786.10 shall be provided by telephone, if the consumer has made a written request, with proper identification for telephone disclosure, and the toll charge, if any, for the telephone call is prepaid by or charged directly to the consumer.

The term "proper identification" as used in subdivision (b) shall mean that information generally deemed sufficient to identify a person. Such information includes documents such as a valid driver's license, social security account number, military identification card, and credit cards. Only if the consumer is unable to reasonably identify himself with the information described above, may an investigative consumer reporting agency require additional information concerning the consumer's employment and personal or family history in order to verify his identity.

The investigative consumer reporting agency shall provide trained personnel to explain to the consumer any information furnished him pursuant to Section 1786.10.

The investigative consumer reporting agency shall provide a written explanation of any coded information contained in files maintained on a consumer. This written explanation shall be distributed whenever a file is provided to a consumer for visual inspection as required under Section 1786.22.

The consumer shall be permitted to be accompanied by one other person of his choosing, who shall furnish reasonable identification. An investigative consumer reporting agency may require the consumer to furnish a written statement granting permission to the consumer reporting agency to discuss the consumer's file in such person's presence.

NEW YORK CORRECTION LAW
ARTICLE 23-A
LICENSURE AND EMPLOYMENT OF PERSONS PREVIOUSLY CONVICTED OF ONE OR MORE CRIMINAL OFFENSES

Section 750. Definitions.
751. Applicability.
752. Unfair discrimination against persons previously convicted of one or more criminal offenses prohibited.
753. Factors to be considered concerning a previous criminal conviction; presumption.
754. Written statement upon denial of license or employment.
755. Enforcement.

§ 750. Definitions. For the purposes of this article, the following terms shall have the following meanings:

"Public agency" means the state or any local subdivision thereof, or any state or local department, agency, board or commission.

"Private employer" means any person, company, corporation, labor organization or association which employs ten or more persons.

"Direct relationship" means that the nature of criminal conduct for which the person was convicted has a direct bearing on his fitness or ability to perform one or more of the duties or responsibilities necessarily related to the license, opportunity, or job in question.

"License" means any certificate, license, permit or grant of permission required by the laws of this state, its political subdivisions or instrumentalities as a condition for the lawful practice of any occupation, employment, trade, vocation, business, or profession. Provided, however, that "license" shall not, for the purposes of this article, include any license or permit to own, possess, carry, or fire any explosive, pistol, handgun, rifle, shotgun, or other firearm.

"Employment" means any occupation, vocation or employment, or any form of vocational or educational training. Provided, however, that "employment" shall not, for the purposes of this article, include membership in any law enforcement agency.

§ 751. Applicability. The provisions of this article shall apply to any application by any person for a license or employment at any public or private employer, who has previously been convicted of one or more criminal offenses in this state or in any other jurisdiction, and to any license or employment held by any person whose conviction of one or more criminal offenses in this state or in any other jurisdiction preceded such employment or granting of a license, except where a mandatory forfeiture, disability or bar to employment is imposed by law, and has not been removed by an executive pardon, certificate of relief from disabilities or certificate of good conduct. Nothing in this article shall be construed to affect any right an employer may have with respect to an intentional misrepresentation in connection with an application for employment made by a prospective employee or previously made by a current employee.

§ 752. Unfair discrimination against persons previously convicted of one or more criminal offenses prohibited. No application for any license or employment, and no employment or license held by an individual, to which the provisions of this article are applicable, shall be denied or acted upon adversely by reason of the individual's having been previously convicted of one or more criminal offenses, or by reason of a finding of lack of "good moral character" when such finding is based upon the fact that the individual has previously been
convicted of one or more criminal offenses, unless:

There is a direct relationship between one or more of the previous criminal offenses and the specific license or employment sought or held by the individual; or

the issuance or continuation of the license or the granting or continuation of the employment would involve an unreasonable risk to property or to the safety or welfare of specific individuals or the general public.

§ 753. Factors to be considered concerning a previous criminal conviction; presumption.

In making a determination pursuant to section seven hundred fifty-two of this chapter, the public agency or private employer shall consider the following factors:

The public policy of this state, as expressed in this act, to encourage the licensure and employment of persons previously convicted of one or more criminal offenses. (b) The specific duties and responsibilities necessarily related to the license or employment sought or held by the person. (c) The bearing, if any, the criminal offense or offenses for which the person was previously convicted will have on his fitness or ability to perform one or more such duties or responsibilities.

The time which has elapsed since the occurrence of the criminal offense or offenses.

The age of the person at the time of occurrence of the criminal offense or offenses.

The seriousness of the offense or offenses.

Any information produced by the person, or produced on his behalf, in regard to his rehabilitation and good conduct.

The legitimate interest of the public agency or private employer in protecting property, and the safety and welfare of specific individuals or the general public.

In making a determination pursuant to section seven hundred fifty-two of this chapter, the public agency or private employer shall also give consideration to a certificate of relief from disabilities or a certificate of good conduct issued to the applicant, which
certificate shall create a presumption of rehabilitation in regard to the offense or offenses specified therein.

§ 754. Written statement upon denial of license or employment. At the request of any person previously convicted of one or more criminal offenses who has been denied a license or employment, a public agency or private employer shall provide, within thirty days of a request, a written statement setting forth the reasons for such denial.
§ 755. Enforcement.

In relation to actions by public agencies, the provisions of this article shall be enforceable by a proceeding brought pursuant to article seventy-eight of the civil practice law and rules.

In relation to actions by private employers, the provisions of this article shall be enforceable by the division of human rights pursuant to the powers and procedures set forth in article fifteen of the executive law, and, concurrently, by the New York city commission on human rights.

Front Drivers License*
Max. file size: 50 MB.
Back Drivers License*
Max. file size: 50 MB.
Front Social Security Card*
Max. file size: 50 MB.
Medical Card*
Max. file size: 50 MB.

5782

APPLICATION FOR EMPLOYMENT

COMMERCIAL DRIVER

Employment History

Experience And Qualifications - Driver

Driving Experience - Class of Equipment

Driving Record

Education

Other Experience and Qualifications

Personal & Confidential Medical Review Questionnaire Commercial Drivers

Essential job functions worksheet commercial truckdriver (Class A & B)

The below disclosure and authorization language is for mandatory use by all account holders

AUTHORIZATION

Motor vehicle certification of violations and annual review of driving record

STATE LAW NOTICES

Type of Business

Contact

A Summary of Your Rights Under the Provisions of California Civil Code Section 1786.22

NEW YORK CORRECTION LAW ARTICLE 23-A LICENSURE AND EMPLOYMENT OF PERSONS PREVIOUSLY CONVICTED OF ONE OR MORE CRIMINAL OFFENSES

A Summary of Your Rights
Under the Provisions of California Civil Code Section 1786.22

NEW YORK CORRECTION LAW
ARTICLE 23-A
LICENSURE AND EMPLOYMENT OF PERSONS PREVIOUSLY CONVICTED OF ONE OR MORE CRIMINAL OFFENSES