• 220 S Hancock St.  McAdoo,  PA  18237
  • 570-929-2022

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Application For Employment

van Hoekelen Greenhouses, Inc.
220 S Hancock St.
McAdoo,  PA  18237
570-929-2022
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*If at current address less than 7 years, list below most recent addresses for the past 7 years. (Click on the Plus sign to add additional Previous Addresses.)

Commercial Driver's License

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CDL Type *
Endorsements (check all that apply)
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Air Brake Restriction? *
Automatic Transmission Restriction
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Current DOT Medical Card *

Driving/Hauling Experience

Education

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Additional Licenses

Accident Review for Past 5 Years

If no Accidents to report, you must check this box.
  No Accidents to report. *
Click on the Plus sign to add additional Accidents.
Last Accident

Traffic Convictions & Forfeitures for Past 5 Years

If no Traffic Convictions or Forfeitures to report, you must check this box.
  No Traffic Convictions or Forfeitures to report. *
Click on the Plus sign to add additional Traffic Convictions or Forfeitures.

Employment History

You must provide accurate dates of employment and phone numbers covering the last ten years (per DOT regulation). We cannot hire you without verifying employment. If you need to list additional employers, click "Add Another Employer" below.
EMPLOYER #1
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Driving/Hauling Experience With This Employer
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Owner Operator Equipment Form

Tractor

Trailer

Straight Truck

Cargo Van

May we contact current employer?          
Yes    No

Authorization

By clicking "Send" below, I certify that this application was completed by me and that the facts contained in this application are true and complete to the best of my knowledge.  I 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 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 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; and have a rebuttal statement attached to the alleged erroneous information, if the previous employer(s) and I cannot agree on the accuracy of the information.

I hereby release, and hold harmless any employers, schools, healthcare providers, firms, or entity that discloses information in accordance with this authorization, as well as my prospective employer, from any liability that may otherwise results from the request for, use of, or disclosure of, any or all of the foregoing information. The above-mentioned investigations and inquiries may include, but are not limited to, information as to my character, general reputation, personal characteristics and mode of living, 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; medical history, made only if and after a conditional offer of employment has been extended; any other public record; and other related matters as may be necessary in arriving at an employment decision.

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.



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This certifies that this application was completed by me and that all entries and the information herein are true and complete to the best of my knowledge.

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Date: 2024-04-26 09:53:12

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Terms of Service

Privacy Policy

INQUIRY TO PAST EMPLOYER

From - Prospective Employer/Contractor To - previous employer

Dear Motor Carrier:
The person listed below has made application to this company for employment or contracting as a Driver and states that he/she was employed by you as   from   to   . If these dates are not correct please provide From     and To     The applicant has waived any claim of liability against you company for information submitted in response to the inquiry - See release form at bottom of this page

Name of Applicant:   

Social Security Number of Applicant:  
Date of Birth:  
1. Is the employment record with your company, including dates, correct as stated above?  
2. What kind of work did applicant do?  
3. If employed as a driver, Specify type of equipment  
4. If Tractor-Trailer please specify type:
5. Total Miles Driven 

6. Number of accidents      Number preventable  

7. Was applicant's drivers license ever suspended or revoked?  
8. Reason for leaving your employ :   
9. Was applicant's general conduct satisfactory?   
10. Is applicant competent for the position applicant is seeking?   
11. Would you re-employ?   
12. Any remarks with regard to questions 1 - 11 above?  
   
 

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.

Previous Employer Inquiry For Driving History & Safety Performance

Previous Employer:
Name:   
Address:   
Phone:   
Email:   
Fax:   

Applicant
Applicant Name:      Social Security:     Date of Birth:  

Date of Employment: From:   To  

Prospective Employer/Contractor:
van Hoekelen Greenhouses, Inc.
220 S Hancock St. McAdoo PA 18237
Jennifer Grier-Quinn
570-929-1933
Confidential Email: jenngq@vhgreenhouses.com
Confidential Fax: 570-929-3719

Prospective Employer's/Contractor's Agent
  
  
  
  
Confidential Email:  
Confidential Fax:   

Section 1 (Applicant)
Applicant Authorization

I,    hereby authorize    to release and forward the information requested in sections2 and 3 of this document concerning my Accident History within the previous 3 years to    (Prospective Employer/Contractor), and/or   (third-party investigation firm).

Applicant's Signature:
Date:    

This information is being requested in compliance with 49 CFR $$ 40.25 and 391.23.

In compliance with 49 CFR $$40.25(g) and 391.23(h), release of this information must be made in a form that ensures confidentiality, such as fax, email, or letter.

Section 2 (Previous Employer)
ACCIDENT HISTORY

The applicant named above was employed by you.   

Employed as (Job Title)  
From Date (mm/yyyy)  
To Date (mm/yyyy)  
Did he/she drive motor vehicle for you?   

ACCIDENTS: Complete the following for any accidents included on your accident registrar ($390.15(b)) that involved the applicant in the 3 years prior to the application date shown above or check here if there is no accident register data for this driver.

Date Location Number of
Injuries		 Number of
Fatalities		 Hazmat
Spill		 Preventable Description
             
             
             

Please provide information concerning any other accidents involving the applicant that were reported to government agencies or insurers or retained under internal company policies:

Signature   
Title   
Date   

Completed By

Name:   
Company:   
Street:   
City, State, Zip:   
Phone:   
Date:   

PSP Consent

Applicant Authorization Consent For Release of Information

Applicant Authorization Consent For Release of Information Form

The release and authorization acknowledge that van Hoekelen Greenhouses, Inc. located at PO BOX 88 McAdoo, PA 18237 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 located at to disclose orally and in writing the results of the verification process to the designated authorized representative of van Hoekelen Greenhouses, Inc.. The results will be used to determine employment eligibility 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 van Hoekelen Greenhouses, Inc., , 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.

Please provide the following information as well as addresses for the last seven (7) years.

 
 
 
 
 
 
 
 
 

Authorization to contact current employer?

  yes      No
 

Other Disclosure and Authorization

Disclosure and Authorization

Pre-Employment Controlled Substance Consent Form

Fair Credit Reporting Act Consumer Rights

Para información en español, visite www.consumerfinance.gov/learnmore o escribe a la Consumer Financial Protection Bureau, 1700 G Street N.W., Washington, DC 20552.

A SUMMARY OF YOUR RIGHTS

UNDER THE FAIR CREDIT REPORTING ACT

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.consumerfinance.gov/learnmore or write to: Consumer Financial Protection Bureau, 1700 G Street N.W., Washington, DC 20552.

  • You must be told if information in your file has been used against you. Anyone who uses a credit report or another type of consumer report to deny your application for credit, insurance, or employment - or to take another adverse action against you - must tell you, and must give you the name, address, and phone number of the agency that provided the information.
  • You have the right to know what is in your file. You may request and obtain all the information about you in the files of a consumer reporting agency (your "file disclosure"). You will be required to provide proper identification, which may include your Social Security number. In many cases, the disclosure will be free. You are entitled to a free file disclosure if:
    • a person has taken adverse action against you because of information in your credit report;
    • you are the victim of identity theft and place a fraud alert in your file;
    • your file contains inaccurate information as a result of fraud;
    • you are on public assistance;
    • you are unemployed but expect to apply for employment within 60 days.
    In addition, all consumers are entitled to one free disclosure every 12 months upon request from each nationwide credit bureau and from nationwide specialty consumer reporting agencies. See www.consumerfinance.gov/learnmore for additional information.
  • You have the right to ask for a credit score. Credit scores are numerical summaries of your credit-worthiness based on information from credit bureaus. You may request a credit score from consumer reporting agencies that create scores or distribute scores used in residential real property loans, but you will have to pay for it. In some mortgage transactions, you will receive credit score information for free from the mortgage lender.
  • You have the right to dispute incomplete or inaccurate information. If you identify information in your file that is incomplete or inaccurate, and report it to the consumer reporting agency, the agency must investigate unless your dispute is frivolous. See www.consumerfinance.gov/learnmore for an explanation of dispute procedures.
  • Consumer reporting agencies must correct or delete inaccurate, incomplete, or unverifiable information. Inaccurate, incomplete or unverifiable information. Inaccurate, incomplete, or unverifiable information must be removed or corrected, usually within 30 days. However, a consumer reporting agency may continue to report information it has verified as accurate.
  • 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.consumerfinance.gov/learnmore.
  • 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.
  • The following FCRA right applies with respect to nationwide consumer reporting agencies:
    CONSUMERS HAVE THE RIGHT TO OBTAIN A SECURITY FREEZE

    You have a right to place a “security freeze” on your credit report, which will prohibit a consumer reporting agency from releasing information in your credit report without your express authorization. The security freeze is designed to prevent credit, loans, and services from being approved in your name without your consent. However, you should be aware that using a security freeze to take control over who gets access to the personal and financial information in your credit report may delay, interfere with, or prohibit the timely approval of any subsequent request or application you make regarding a new loan, credit, mortgage, or any other account involving the extension of credit.
    As an alternative to a security freeze, you have the right to place an initial or extended fraud alert on your credit file at no cost. An initial fraud alert is a 1-year alert that is placed on a consumer’s credit file. Upon seeing a fraud alert display on a consumer’s credit file, a business is required to take steps to verify the consumer’s identity before extending new credit. If you are a victim of identity theft, you are entitled to an extended fraud alert, which is a fraud alert lasting 7 years.
    A security freeze does not apply to a person or entity, or its affiliates, or collection agencies acting on behalf of the person or entity, with which you have an existing account that requests information in your credit report for the purposes of reviewing or collecting the account. Reviewing the account includes activities related to account maintenance, monitoring, credit line increases, and account upgrades and enhancements.
  • 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.consumerfinance.gov/learnmore.

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. For information about your federal rights, contact:

TYPE OF BUSINESS: CONTACT:
1.a. Banks, savings associations, and credit unions with total assets of over $10 billion and their affiliates a. Consumer Financial Protection Bureau 1700 G Street, N.W. Washington, DC 20552
b. Such affiliates that are not banks, savings associations, or credit unions also should list, in addition to the CFPB: b. Federal Trade Commission Consumer Response Center 600 Pennsylvania Avenue, N.W. Washington, DC 20580
2. To the extent not included in item 1 above:
a. National banks, federal savings associations, and federal branches and federal agencies of foreign banks		 a. Office of the Comptroller of the Currency Customer Assistance Group 1301 McKinney Street, Suite 3450 Houston, TX 77010-9050
b. State member banks, branches and agencies of foreign banks (other than federal branches, federal agencies, and Insured State Branches of Foreign Banks), commercial lending companies owned or controlled by foreign banks, and organizations operating under section 25 or 25A of the Federal Reserve Act. b. Federal Reserve Consumer Help Center P.O. Box 1200 Minneapolis, MN 55480
c. Nonmember Insured Banks, Insured State Branches of Foreign Banks, and insured state savings associations c. FDIC Consumer Response Center 1100 Walnut Street, Box #11 Kansas City, MO 64106
d. Federal Credit Unions d. National Credit Union Administration Office of Consumer Financial Protection (OCFP) Division of Consumer Compliance Policy and Outreach 1775 Duke Street Alexandria, VA 22314
3. Air carriers Asst. General Counsel for Aviation Enforcement & Proceedings Aviation Consumer Protection Division Department of Transportation 1200 New Jersey Avenue, S.E. Washington, DC 20590
4. Creditors Subject to the Surface Transportation Board Office of Proceedings, Surface Transportation Board Department of Transportation 395 E Street, S.W. Washington, DC 20423
5. Creditors Subject to the Packers and Stockyards Act, 1921 Nearest Packers and Stockyards Administration area supervisor
6. Small Business Investment Companies Associate Deputy Administrator for Capital Access United States Small Business Administration 409 Third Street, S.W., Suite 8200 Washington, DC 20416
7. Brokers and Dealers Securities and Exchange Commission 100 F Street, N.E. Washington, DC 20549
8. Federal Land Banks, Federal Land Bank Associations, Federal Intermediate Credit Banks, and Production Credit Associations Farm Credit Administration 1501 Farm Credit Drive McLean, VA 22102-5090
9. Retailers, Finance Companies, and All Other Creditors Not Listed Above Federal Trade Commission Consumer Response Center 600 Pennsylvania Avenue, N.W. Washington, DC 20580 (877) 382-4357

I acknowledge that I have read and understand the federal FCRA Summary of Rights and have been given the opportunity to copy/print the Summary of Rights and agree to use an electronic signature to demonstrate my consent.

Drivers Rights Pertaining to Release of Information
under Regulation 391.23

Motor carriers have the responsibility to make the following investigations and inquiries with respect to each driver employed, other than a person who has been a regularly employed driver of the motor carrier for a continuous period which began before January 1, 1971.

  • (a)(1) An inquiry into the driver's driving record during the preceding three years to the appropriate agency of every State in which the driver held a motor vehicle operator's license or permit during those preceding three years.
  • (a)(2) An investigation of the driver's employment record during preceding three years.
  • (b) A copy of the driver record(s) obtained in response to the inquiry or inquiries to each State driver record agency as required must be placed in the Driver Qualification File within 30 days of the date the driver's employment begins and be retained in compliance with 391.51.
  • (c) Replies to the investigations of the driver's safety performance history must be placed in the Driver Investigation History File within 30 days of the date the driver's employment begins. This goes into effect after October 29, 2004.
  • (d) Prospective motor carrier must investigate the information from all previous employers of the applicant that employed the driver to operate a CMV within the previous three years. This information must cover general driver identification and employment verification information, data elements as specified in 390.15 for accident involving the driver that occurred in the three-year period preceding the date of the employment application, and accidents the previous employer may wish to provide.
  • (e) Prospective motor carriers must investigate the information from all previous DOT regulated employers that employed the driver within the previous three years from the date of the employment application in a safety-sensitive function that required alcohol and controlled substance testing specified by 49 CFR Part 40.

Drivers have the following rights:

  1. The right to review information provided by previous employers
  2. The right to have errors in the information corrected by the previous employer and for that employer to resend the corrected information to the prospective employer
  3. The right to have a rebuttal statement attached to the alleged erroneous information, if the previous employer and the driver cannot agree on the accuracy of the information.

Drivers who wish to review previous employer-provided information must submit a written request to the prospective employer when applying of as late as 30 days after employed or being notified of denial of employment. The prospective employer must provide this information to the applicant within five business days of receiving the written request. If the driver has not arranged to pick up or receive the requested records within 30 days pf the prospective employer making them available, the prospective motor carrier may consider the driver to have waived his/her request to review the records.

Drivers wishing to request correction of erroneous information in records must send the request for the correction to the previous employer that provided the records. After October 29, 2004, the previous employer must either correct and forward the information to the prospective motor carrier employer or notify the driver within 15 days of receiving the driver's request to correct the data that it does not agree to correct the data. Drivers wishing to rebut information in records must send the rebuttal to the previous employer with instructions to include the rebuttal in the driver's Safety Performance History.

I acknowledge that I have read and understand the contents of this document.

Consent for Limited Queries of the FMCSA Drug and Alcohol Clearinghouse