Acceptance of any driver not meeting the preceding eligibility is subject to approval of Blackman Transport Inc. and its insurance company.
I have read the above information and agree to the terms. *
In compliance with Federal and State equal employment opportunity laws, qualified applicants are considered for all positions without regard to race, color, religion, sex, national origin, age, marital status, non-job disability, or any other protected group status.
If yes, please provide a full explanation below. The conviction of a crime will not automatically result in the declination of employment.
Select highest level of education completed.
Please list all drivers licenses held in the last three years.
If you answered "yes" to A or B, providing the details below.
Accident records for the past three years.
Traffic convictions & forfeitures for the past three years (Other than parking violations). If none, write none.
DOT requires that all employment for 3 years previous and/or commercial driving experience during the last 10 years be provided. Please be sure to list ALL PREVIOUS EMPLOYMENT! Any gaps in employment must be explained. Employment history will be verified through DAC and previous employers. In the event that you were self-employed or your previous employers are no longer in business, you will need to provide proof of employment such as tax records or payroll documents. Start with your most recent employer.
This refers to any gap in the above employment history.
I understand that I must provide my complete employment history for the past three years, and all CDL required employment for the seven years preceding that. Any gaps in employment for a period of longer than one month are explained as follows:
I authorize you to make sure investigations and inquires to my personal, employment, financial or medical history and other related matters as may be necessary in arriving at an employment decision. (Generally, inquires regarding medical history will be made only if and after a conditional offer of employment has been extended). I hereby release employers, schools, health care providers and other persons from all liability in responding to inquires and releasing information in connection with my application.
I understand that information I provide regarding current and/or previous employers may be used, and those employer(s) will be contacted, for the purpose of investigating my safety performance history as required by 49 CFR 391.23 (d) and (e). I understand that I have the right to
In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations of Bloxsom Transportation, Inc.
I understand that, as an applicant for a position with this company, I may be asked to demonstrate that I am capable of performing tasks, which are pertinent to the job. I also understand that if offered a job, it may be conditioned on the result of a physical examination and drug test.
I further certify that I am a genuine applicant for employment and this application is being submitted for the sole purpose of seeking employment with the employer and for no other reason.
I agree to furnish such additional information and complete such examinations as may be required to complete my employment file.
By clicking the checkbox below, I certify 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 certify that I have read and understand this employment application. *
I understand that as required by Federal Motor Carrier Regulations 49 CFR Part 382 and company policy, all prospective drivers must submit to a controlled substance test involving collection of a urine sample that will be tested for the following substances; marijuana, cocaine, opiates, amphetamines and phencyclidine (PCP).
I understand that if I test positive for the use of controlled substances, I am not medically qualified to operate a commercial motor vehicle. I also understand I will be given a reasonable opportunity to confer with the company’s medical review officer before and positive drug test results are reported to the company.
The results of the drug test will be maintained by the medical review officer of the company, who will report to the company whether the test result was negative or positive. The results of any test will not be released to any parties, except as provided in § 40.37, without my written authorization.
I hereby agree to submit to a urine drug test. *
PART 40.25(j) requires an employer to ask an applicant/driver whether he or she has tested positive, or refused to test, or any pre-employment alcohol or drug test administered by an employer to which the applicant/driver applied for, but did not obtain, safety-sensitive transportation work covered by DOT agency alcohol and drug testing rules during the past two (2) years. If the applicant/driver admits that he or she had a positive drug test or a refusal to test, the employer cannot use the employee to perform safety-sensitive functions, until and unless the employee documents successful completion of the return to duty process (see §40.25(b)(5) and (e)).
The applicant/driver is required by §40.25(j) to answer the items listed below.
During the past two (2) years, have you tested positive on any pre-employment alcohol or drug test administered by an employer to which you applied for, but did not obtain, safety-sensitive transportation work covered by Department of Transportation (DOT) drug and alcohol testing rules?
During the past two (2) years, have you refused to test on any pre-employment alcohol or drug test administered by an employer to which you applied for, but did not obtain, safety-sensitive transportation work covered by the Department of Transportation (DOT) drug and alcohol testing rules?
If you answered YES to either of the questions above, please provide documentation of your successful completion of the return to-duty process required by Part 40 Subpart O.
I certify that the information provided on this document is true and correct. *
In accordance with provisions of Section 604(b) (2) (A) of the Fair Credit Reporting Act, Public Law 91-508, as amended by the Consumer Credit Reporting Act of 1996 (Title II, Subtitle D, Chapter I, of Public Law 104-208), you are being informed that reports verifying your previous employment, previous drug and alcohol test results, and your driving record may be obtained on you for employment purposes. These reports are required by Section 382.413, 391.23 and 391.25 of the Federal Motor Carrier Safety Regulations.
It is agreed and understood that this the employer or his/her agents may investigate the applicant’s background to ascertain any and all information of concern to applicant’s record, whether same is of record or not. The applicant releases employers and persons named herein from all liability for any damages because of his/her furnishing such information.
The applicant agrees to furnish such additional information and complete such examination as may be required to complete his employment file.
It is agreed and understood that if hired, the employee may be on a probationary period during which he/she may be discharged without recourse.
In connection with your application for employment with Blackman Transport 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.
If you agree that the Prospective Employer may obtain such background reports, please read the following and sign below:
I authorize Blackman Transport 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.
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 12/22/2015