In connection with your application for employment with Franklin Well Services, LLC, 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). 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.
In the initial recruitment process you were advised that your acceptance of this position is with the understanding that the offer is contingent upon a full investigation of:
In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge.
CURRENT AND PREVIOUS THREE YEARS RESIDENCY
Tractor - And Semi-Trailer
Tractor - Two Trailers
ACCIDENT RECORD FOR PAST 3 YEARS OR MORE
TRAFFIC CONVICTIONS AND FORFEITURES FOR THE PAST 3 YEARS (OTHER THAN PARKING VIOLATIONS)
A. Have you ever been denied a license, permit or privilege to operate a motor vehicle?
B. Has any license, permit or privilege ever been suspended or revoked?
C. Have you ever been convicted of any criminal act involving the use of a CMV or while driving a CMV?
D. Have you ever been convicted of a felony?
E. Have you ever refused to be tested for drugs or alcohol for DOT-mandated test?
F. Have you ever tested positive for drugs or alcohol on a DOT-mandated test?
G. Have you ever tested positive for drugs or alcohol for any DOT-mandated pre-employment test for a job you applied for but did not obtain?
CERTIFICATION OF COMPLIANCE WITH DRIVER LICENSE REQUIREMENTS
DRIVER REQUIREMENTS: Parts 383 and 391 of the Federal Motor Carrier Safety Regulations contain some requirements that you as a driver must comply with. These requirements are in effect as of July 1, 1987. They are as follows:
DRIVER CERTIFICATION: I certify that I have read and understand the above requirements.
The following license is the only one I will possess:
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).
Must list the complete mailing address: street number and name, city, state and zip code.
Were you subject to the Federal Motor Carrier Safety Regulations (FMCSRs) while employed by the previous employer?
Was the previous job position designated as a safety sensitive function in any DOT regulated mode, subject to alcohol and controlled substances testing requirements as required by 49 CFR Part 40?
SECOND TO LAST EMPLOYER:
THIRD TO LAST EMPLOYER:
TO BE READ AND SIGNED BY APPLICANT
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 Franklin Well Services.
"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:
I have been informed that my previous DOT Regulated employment history in the previous 3 years can be reviewed by me submitting a written request to the prospective employer, which may be done at any time, including when applying or as late as 30 days after being employed or being notified of denial of employment. This company has advised me that within 5 business days after receiving my request or within 5 business days of receiving the information, they will supply the information to me. This company has advised me that if I have not arranged to pick up or receive the requested records from previous employers within thirty (30) days of making them available, this company may consider I have waived the request to review the records.
All information is to be used in the decision making for employment with this company.
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.
Note: A motor carrier may require an applicant to provide information in addition to the information required by the Federal Motor Carrier Safety Regulations.
SAFETY PERFORMANCE HISTORY RECORDS REQUEST
HEREBY AUTHORIZE MY PREVIOUS EMPLOYER
To release and forward the information requested by section 2 of this document concerning my dates and nature of employment as well as any DOT-recordable accident history within the previous three years of my employment dates. (M/Y OF EMPLOYMENT DATES)
TO MY PROSPECTIVE EMPLOYER
In 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, letter, or e-mail.