Please either download and fill out this form and return to firstname.lastname@example.org
→Downloadable / Printable Form
OR Fill out the form in its entirety below:
The information requested on this form is required by federal law (49 CFR) to be provided by any driver applying for a commercial driver position as defined in 49 CFR 390.5. Failure to complete required areas can place both the applicant and carrier in violation of federal law. Information provided will be verified by carrier as required under various parts of 49 CFR, including Part 382 and Part 391. If unsure of question or require help with competing form please ask carrier representative.
PLEASE PRINT CLEARLY AND SIGN YOUR FULL LEGAL NAME AT THE END WHERE REQUIRED.
FALSE STATEMENTS MAY RESULT IN REFUSAL TO HIRE OR IMMEDIATE TERMINATION.
Everything with an * is a required field.
All applicants must provide the following information for any previous employer during the preceding 3 years. Complete all areas below. Applicants shall also provide an additional 7 years of information for those employers for whom the applicant has operated a CMV.
(NOTE: List employers in reverse order starting with the most recent.
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.
By completing and signing this application, I understand that all necessary reports including but not limited to: MVR, 20/20 Criminal, Social Security Verification, DAC, Employment History and CDLIS will be pulled by a third party provider and reviewed for my potential qualification. I further understand such reports will be made available to me at my request at no expense within 60 days from the date the reports were pulled
Transport Worldwide, LLC(“Prospective Employer”), it 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.
The Prospective Employer cannot obtain background reports from FMCSA unless you consent in writing. If you agree that the Prospective Employer may obtain such background reports, please read the following and sign below:
2. I authorize Transport Worldwide, 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 consenting to 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.
3. 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 am challenging 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.
4. Please note: 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 FMCSR violations that have been adjudicated by a court of law will also appear, and remain, on a PSP report.
I have read the above Notice Regarding Background Reports provided to me by Prospective Employer and I understand that if I sign
this consent form, 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.