Date of Application:
Charles Bailey Trucking, Inc.
P.O. Box 2998
Cookeville, TN 38502
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, veteran status, non-job related disability, or any other protected group status.
I authorize you to make such investigations and inquiries of 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:
List your addresses of residency for the past 3 years.
Do you have the legal right to work in the United States? YesNo
Date of Birth:
Can you provide proof of age? YesNo
Have you worked for this company before? YesNo
10yr history w/ dates & phone numbers
All driver applicants to drive in interstate commerce must provide the following information on all employers during the preceding 3 years. List complete mailing address, street number, city, state and zip code.
Applicants to drive a commercial motor vehicle* intrastate or interstate commerce shall also provide an additional 7 years information on those employers for whom the applicant operated such vehicle.
(NOTE: List employers in reverse order, starting with the most recent)
*Includes vehicles having a GVWR of 26,001 lbs. or more, vehicles designed to transport 16 or more passengers (including the driver), or any size vehicle used to transport hazardous materials in a quantity requiring placarding.
The Federal Motor Carrier Safety Regulations (FMCSRs) apply to anyone operating a motor vehicle on a highway in interstate commerce to transport passengers or property when the vehicle: (1) weighs or has a GVWR of 10,001 pounds or more, (2) is designed or used to transport more than 8 passengers (including driver), OR (3) is of any size and is used to transport hazardous materials in a quantity requiring placarding.
(But not limited to)
Please read and initial
For the past 3 years or more
For the past 3 years (other than parking violations)
List all driver licenses or permits held in the past 3 years
If the answer to either A or B is YES, give details:
List states operated in for last five years:
Show special courses or training that will help you as a driver:
Which safe driving awards do you hold and from whom?
Show any trucking, transportation or other experience that may help in your work for this company
List courses and training other than shown elsewhere in this application
List special equipment or technical materials you can work with
(other than those already shown)
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.
The prospective employee is required by Sec. 40.25(j) to respond to the following questions.
I certify that the information provided on this document is true and correct.
Prospective Employee Signature:
the person below has authorized you to release details of his/her previous employment:
I hereby authorize this company to release all records of employment, including Safety Performance History as required by 49 CFR 40.25b, assessments of my job performance ability, and fitness, to each and every company, (or authorized agent), which may request such information in connection with my application for employment with said company. I hereby refuse this company from any and all liability of any type as a result of providing the above mentioned information to the above mentioned person.
I hereby authorize you to release the following information to CHARLES BAILEY TRUCKING, INC ("Prospective Employer")
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 connection with your application for employment with CHARLES BAILEY TRUCKING, 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 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 CHARLES BAILEY TRUCKING INC ("Prospective Employer") to access the FMCSA Pre-Employment Screening Program (PSP)system to seek information regarding my commercial driving 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 am challenging 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, 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 Notice Regarding Background Reports provided to me by Prospective Employer and I understand that if I sign this consent form, 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 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 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
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