If you previously saved an application and want to retrieve it please enter the following:
By clicking "Send" below, I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that, if employed, any falsified statements on this application shall be grounds for dismissal. Under the provisions of the Fair Credit Reporting Act, the Americans With Disabilities Act, the Drivers Privacy Protection Act and all other applicable federal, state, and local laws I authorize investigation of all statements contained herein as well as authorize the references and employers listed to give you any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise.
I hereby release and hold harmless any person, firm, or entity that discloses information in accordance with this authorization, as well as my prospective employer, and its agents, from any liability that may otherwise result from the request for, use of, or disclosure of, any or all of the foregoing information. The above-mentioned investigations may include, but are not limited to, information as to my character, general reputation, work history, or lifestyle, discerned through employment and education verifications; personal references; personal interviews; my personal credit history based on reports from any credit bureau; my driving history, including any traffic citations; a social security number verification; present and former addresses; criminal and civil history records; or any other public record.
I understand that consumer reports which may contain public record information may be requested, at the discretion of my prospective employer, which may include names, dates of employment, reason for termination, work experience, traffic records, workers compensation claims, etc. I have the right, under the provisions of the Fair Credit Reporting Act and the Drivers Privacy Protection Act to request all such information from the reporting agency, upon proper identification, and to request the nature and substance of all information; and the receipt of any reports on me, which the reporting agency has, or will, furnish for the two preceding years. I am also entitled to a copy of my consumer rights under the Fair Credit Reporting Act. I also understand and agree that no representative of the company has any authority to enter into any agreement for employment for any specified period of time, or to make any agreement contrary to the forgoing, unless it is in writing and signed by an authorized company representative.
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.
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The release and authorization acknowledge that this Company may now, or at any time while I am employed, conduct a verification of my
education, employment history, social security, credit history, motor vehicle records, contact my personal references, and
receive any criminal history record information pertaining to me which may be in the files of any Federal, State, or Local criminal
justice agency in any state, and/or other information as deemed necessary to fulfill the job requirements. Also, if an offer of employment
has been made, I authorize review of my worker's compensation claims history.
I authorize any agent of my prospective employer to disclose orally and in writing the results of the verification process to the designated authorized representative of this company. The results will be used to determine employment eligibilty under this company's employment policies.
I have read and understand this release and consent, and I authorize the background verifications. I authorize persons, schools, current and former employers, and other organizations and agencies to provide agents of my prospective employer with all information that may be requested, and I hereby release all of the persons and agencies providing such information from any and all claims and damages connected with their release of any requested information. I agree that any copy of this document is as valid as the original.
I do hereby agree to forever release and discharge this company, its agents, and their associates to the full extent permitted by-law from any claims damages, losses, liability, costs, and expenses, or any other charge or complaint filed with any agency arising from the retrieving and reporting of information. According to the Federal Fair Credit Reporting Act, I am entitled to know if employment was denied as a result of information obtained by my prospective employer, and to receive, upon written request, a disclosure of the pubic record information and of the nature and scope of the investigative report.
, (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.
I have carefully read and understand this Disclosure and Authorization form and the attached summary of rights under the Fair Credit Reporting Act. By my signature below, I consent to the release of consumer reports and investigative consumer reports prepared by a consumer reporting agency to the Company and its designated representatives and agents. I understand that if the Company hires me, my consent will apply, and the Company may obtain reports, throughout my employment.
I also understand that information contained in my job application or otherwise disclosed by me before or during my employment, if any, may be used for the purpose of obtaining consumer reports and/or investigative consumer reports.
By my signature below, I authorize law enforcement agencies, learning institutions (including public and private schools and universities), information service bureaus, credit bureaus, record/data repositories, courts (federal, state and local), motor vehicle records agencies, my past or present employers, the military, and other individuals and sources to furnish any and all information on me that is requested by the consumer reporting agency.
By my signature below, I certify the information I provided on this form is true and correct. I agree that this Disclosure and Authorization form in original, faxed, photocopied or electronic (including electronically signed) form, will be valid for any reports that may be requested by or on behalf of the Company.
California, Minnesota or Oklahoma applicants only -- You will be provided with a free copy of any consumer reports or investigative consumer reports obtained on you if you check the box below.
* This information will be used only for background screening purposes and will not be taken into consideration in any employment decisions.
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:
I understand that as required by the Federal Motor Carrier Safety Regulations, Title 49 United States Code of Federal Regulations, Section 391.103 and Exclusive Staffing LLC 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 Exclusive Staffing LLC, 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 thetest results to Exclusive Staffing LLC 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 Exclusive Staffing LLC 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.
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