If you previously saved an application and want to retrieve it please enter the following:
|From - prospective employer||To - previous employer|
I hereby authorize you to release all information regarding my services, character and conduct while in your employ, and you are released from any and all liablility which may result from furnishing such information.
In connection with your application for employment with , 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.
, (the "Company") may request background information about you from a consumer reporting agency in connection with your employment application and for employment purposes. This information may be obtained in the form of consumer reports and/or investigative consumer reports. These reports may be obtained at any time after receipt of your authorization and, if you are hired by the Company, throughout your employment.
, or another consumer reporting agency, will obtain the reports for the Company. is located at and can be contacted at . The reports may contain information bearing on your character, general reputation, personal characteristics, mode of living and credit standing. The types of information that may be obtained include, but are not limited to: social security number verifications; credit reports; criminal records checks; public court records checks; driving records checks; educational records checks; employment verifications; personal and professional references checks; licensing and certification records checks; drug testing results; etc. The information contained in the reports will be obtained from private and public record sources, including, as appropriate, personal interviews with sources, such as neighbors, friends and associates.
You may request more information about the nature and scope of any investigative consumer reports by contacting the Company at: . A summary of your rights under the Fair Credit Reporting Act is also being provided to you.
If you are a California, Maine, New York or Washington applicant, please also note:
CALIFORNIA: Under section 1786.22 of the California Civil Code, you may view the file maintained on you during normal business hours. You may also obtain a copy of this file, upon submitting proper identification and paying the costs of duplication services, by appearing at offices in person, during normal business hours and on reasonable notice, or by mail. You may also receive a summary of the file by telephone, upon submitting proper identification. has trained personnel available to explain your file to you, including any coded information. If you appear in person, you may be accompanied by one other person, provided that person furnishes proper identification.
NEW YORK: You have the right, upon request, to be informed of whether or not a consumer report was requested. If a consumer report is requested, you will be provided with the name and address of the consumer reporting agency furnishing the report. You may inspect and receive a copy of the report by contacting that agency.
MAINE: You have the right, upon request, to be informed of whether an investigative consumer report was requested, and if one was requested, the name and address of the consumer reporting agency furnishing the report. You may request and receive from the Company, within five business days of our receipt of your request, the name, address and telephone number of the nearest unit designated to handle inquiries for the consumer reporting agency issuing an investigative consumer report concerning you. You also have the right, under Maine law, to request and promptly receive from all such agencies copies of any such reports.
WASHINGTON STATE: If we request an investigative consumer report, you have the right, upon written request made within a reasonable period of time after your receipt of this disclosure, to receive from us a complete and accurate disclosure of the nature and scope of the investigation we requested. You also have the right to request from the consumer reporting agency a written summary of your rights and remedies under the Washington Fair Credit Reporting Act.
Para informacion en Espanol, visite www.ftc.gov/credit o escribe a la FTC Consumer Response Center, Room 130-A 600 Pennsylvania Ave., N.W., Washington, DC 20580
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.ftcgov/credit or write to: Consumer Response Center, Room 130-A, Federal Trade Commission, 600 Pennsylvania Ave. N.W., Washington, DC 20580.
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.ftc.gov/credit.
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, visit www.ftc.gov/credit.
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 consumer protection agency or your state Attorney General. Federal enforcers are:
|TYPE OF BUSINESS:||PLEASE CONTACT:|
|Consumer reporting agencies, creditors and others not listed below||Federal Trade Commission: Consumer Response Center - FCRA Washington, DC 20580 1-877-382-4357|
|National banks, federal branches/agencies of foreign banks (word "National" or initials "N.A." appear in or after bank's name)||Office of the Comptroller of the Currency Compliance Management, Mail Stop 6-6 Washington, DC 20219 800-613-6743|
|Federal Reserve System member banks (except national banks, and federal branches/agencies of foreign banks)||Federal Reserve Board Division of Consumer & Community Affairs Washington, DC 20551 202-452-3693|
|Savings associations and federally chartered savings banks (word "Federal" or initials "F.S.B." appear in federal institution's name)||Office of Thrift Supervision Consumer Complaints Washington, DC 20552 800-842-6929|
|Federal credit unions (words "Federal Credit Union" appear in institution's name)||National Credit Union Administration 1775 Duke Street Alexandria, VA 22314 703-519-4600|
|State-chartered banks that are not members of the Federal Reserve System||Federal Deposit Insurance Corporation Consumer Response Center 2345 Grand Avenue, Suite 100 Kansas City, MO 64108-2638 1-877-275-3342|
|Air, surface, or rail common carriers regulated by former Civil Aeronautics Board or Interstate Commerce Commission||Department of Transportation, Office of Financial Management Washington, DC 20590 202-366-1306|
|Activities subject to the Packers and Stockyards Act, 1921||Department of Agriculture Office of Deputy Administrator- GIPSA Washington, DC 20250 202-720-7051 Washington, DC 20250 202-720-7051|
I understand that as required by the Federal Motor Carrier Safety Regulations, Title 49 United States Code of Federal Regulations, Section 391.103 and Lilly Trucking of Virginia company policy, all prospective drivers must submit to a controlled substances test.
I agree to provide a urine sample at a location and time designated by Lilly Trucking of Virginia, to be tested for controlled substances.
I also understand that if I test positive for use of controlled substances, I am not medically qualified to operate a commercial motor vehicle or perform safety-sensitive functions.
I also understand that the results of the controlled substances test will be examined by a Medical Review Officer who will report the test results to Lilly Trucking of Virginia and/or its screening agents, including , ,. My results will not be released to any additional parties without my written authorization.
I agree to hold harmless Lilly Trucking of Virginia and its agents from any liability with regard to the collection and testing of my specimens, or the use of my controlled substance test results in connection with my employment or consideration for employment.