Please complete all required fields!
Section 383.21 FMCSR states "No person who operates a commercial motor vehicle shall at any time have more than one driver's license". I certify that I do not have more than one motor vehicle license, the information for which is listed below.
(Other than parking violations)
Applicants that desire to drive in intrastate/interstate commerce must provide the following information on all employers during the previous three years. You must give the same information for all employers you have driven a commercial motor vehicle for the seven years prior to the initial three years (total of ten years employment record).
I authorize you to make sure investigations and inquiries to my personal, employment, financial or medical history and other related matters as may be necessary in arriving at an employment decision. (Generally, inquiries 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 inquiries and releasing information in connection with my application.
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 the Company.
"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:Review information provided by current/previous employers;Have errors in the information corrected by previous employers and for those previous employers to re-send the corrected information to the prospective employer; andHave a rebuttal statement attached to the alleged erroneous information, if the previous employer(s) and I cannot agree on the accuracy of the information"
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.
A motor carrier may require an applicant to provide information in addition to the information required by the Federal Motor Carrier Safety Regulations.
Please provide information for each employer in the previous 3 years.
To release and forward the information requested concerning my Alcohol and Controlled Substances Testing records within the previous 3 years from
Prospective Employer: Rock On EnterprisesAttention: Human ResourcesTelephone: (320) 257-5539Street: 3100 7th Street SouthCity, State, Zip: Waite Park, MN 56387In compliance with §40.25(g) and 391.23(h), release of this information must be made in a written form that ensures confidentiality, such as fax, email, or letter.Prospective employer's fax number: (320) 320-2912Prospective employer's email address: firstname.lastname@example.org
This information is being requested in compliance with §40.25(g) and 391.23.
Prospective Employer: Rock On EnterprisesAttention: Human ResourcesTelephone: (320) 257-5539Street: 3100 7th Street SouthCity, State, Zip: Waite Park, MN 56387In compliance with §40.25(g) and 391.23(h), release of this information must be made in a written form that ensures confidentiality, such as fax, email, or letter.Prospective employer's fax number: (320) 230-2912Prospective employer's email address: email@example.com
IMPORTANT NOTICE REGARDING BACKGROUND REPORTS FROM THE PSP Online Service
In connection with your application for employment with Rock On Enterprises, 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 Rock On Enterprises, 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.
This form is made available to monthly account holders by NICT 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 provided in paragraphs 1-4 of this document to obtain an Applicant's consent. The language must be used in whole, exactly as provided. The language may be included with other consent forms or language at the discretion of the account holder, provided the four paragraphs remain intact and the language is unchanged.
I hereby authorize you to release the following information to Midwest Compliance Inc. for purposes of investigation as required by Sections §391.23 and §391.25 of the Federal Motor Carrier Safety Regulations. You are released from any and all liability, which may result from furnishing such information.
In accordance with the provisions of Section 604 and 607 of the Fair Credit Reporting Act Public Law 91-508, I hereby certify the following:
I also hereby certify that this report request and the above applicant's release notice meet the definition of "permissible uses" of state motor vehicle records under the provisions of the Driver's Privacy Protection Act of 1994.
Midwest Compliance INC.100 2nd Ave South, Suite 104Sauk Rapids, MN 56379
As a government contractor, Rock On Enterprises, Inc. must comply with all applicable city, state and federal affirmative action laws. Because of these responsibilities, we are required to keep records and perform certain analyses on the race and gender status of our applicant pool. Since such analyses are only possible if we know the EEO profile of our applicants, we are using this means to ask you to complete this survey and return it to us promptly.
While your completing this survey is voluntary, for statistical analysis to be meaningful, we must have information on as many applicants as possible. The information which applicants provide does not affect their prospects for employment and is treated very confidentially.
We thank you in advance for your assistance in helping us perform the necessary analyses.
Rock On Enterprises, Inc 3100 7th Street South Waite Park, MN 56387
Phone 320-230-2998 Fax 320-230-2912
Rock On Trucks, Inc