Job Application

DRIVER APPLICATION

In compliance with Federal and State equal opportunity laws, qualified applicants are considered for all positions without regard to race, religion, sex, national origin, age marital status, or non-job related disability.

TO BE READ AND SIGNED BY APPLICANT

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 investigation my safety performance history as required by 49 CFR 391.23(d) and (e).
I also understand that Global Expedited LLC. 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

Applicant Signature:

Date:


DRIVER NAME(required)

ADDRESS

CITY

STATE

ZIP

PHONE NUMBER

CELL PHONE

FAX NUMBER

E-MAIL

DATE OF BIRTH

SOCIAL SECURITY NUMBER

CDL NUMBER

STATE

ARE YOU LEGALLY AUTHORIZED TO WORK IN THE U.S. ?
YESNO

HOW MANY YEARS OF EXPERIENCE DO YOU HAVE

TYPE OF EQUIPMENT

APPROXIMATELY DRIVEN MILES

PREVIOUS ADDRESSES FOR THE PAST THREE (3) YEARS

Year 1

ADDRESS

CITY

STATE

ZIP

FROM

TO

Year 2

ADDRESS

CITY

STATE

ZIP

FROM

TO

Year 3

ADDRESS

CITY

STATE

ZIP

FROM

TO

Please list the name of the person who referred you to our company:


WORK EXPERIENCE

DRIVER APPLICANT NAME:

SOCIAL SECURITY NUMBER:

In accordance with 391.21 & .23 of the Federal Motor Carrier Safety Regulations (FMCSR), an applicant must list all previous work experience for the three (3) years
prior to the date of application shown on page one, as well as all commercial driving experience for seven (7) years prior to those three years, for a total of 10 years.

PLEASE LIST STARTING WITH MOST RECENT EMPLOYER, USE ADDITIONAL SHEET IF NEEDED

CURRENT OR LAST EMPLOYER COMPANY NAME:

MC#

ADDRESS:

CITY

STATE

ZIP

PHONE:

FAX:

E-MAIL:

CONTACT PERSON:

REASON FOR LEAVING?

JOB DESCRIPTION:

FROM:

TO:

CFR Part 40? YESNO *Was this job subject to FMCSA Regulations? YESNO
**ACCOUNT FOR PERIOD BETWEEN JOBS (include reason)

SECOND TO LAST EMPLOYER COMPANY NAME:

MC#

ADDRESS:

CITY

STATE

ZIP

PHONE:

FAX:

E-MAIL:

CONTACT PERSON:

REASON FOR LEAVING?

JOB DESCRIPTION:

FROM:

TO:

CFR Part 40? YESNO *Was this job subject to FMCSA Regulations? YESNO
**ACCOUNT FOR PERIOD BETWEEN JOBS (include reason)

THIRD TO LAST EMPLOYER COMPANY NAME:

MC#

ADDRESS:

CITY

STATE

ZIP

PHONE:

FAX:

E-MAIL:

CONTACT PERSON:

REASON FOR LEAVING?

JOB DESCRIPTION:

FROM:

TO:

CFR Part 40? YESNO *Was this job subject to FMCSA Regulations? YESNO
**ACCOUNT FOR PERIOD BETWEEN JOBS (include reason)

* The Federal Motor Carrier Safety Regulations 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 9 or more passengers, or 3) is of any size and is used to
transport hazardous materials in a requiring pleading.
** Any gaps in employment more than 30 days and/or unemployment must be explained.

Applicant Signature:

Date:


WORK EXPERIENCE

DRIVER APPLICANT NAME:

SOCIAL SECURITY NUMBER:

In accordance with 391.21 & .23 of the Federal Motor Carrier Safety Regulations (FMCSR), an applicant must list all previous work experience for the three (3) years
prior to the date of application shown on page one, as well as all commercial driving experience for seven (7) years prior to those three years, for a total of 10 years.

PLEASE LIST STARTING WITH MOST RECENT EMPLOYER, USE ADDITIONAL SHEET IF NEEDED

FOURTH TO LAST EMPLOYER COMPANY NAME:

MC#

ADDRESS:

CITY

STATE

ZIP

PHONE:

FAX:

E-MAIL:

CONTACT PERSON:

REASON FOR LEAVING?

JOB DESCRIPTION:

FROM:

TO:

CFR Part 40? YESNO *Was this job subject to FMCSA Regulations? YESNO
**ACCOUNT FOR PERIOD BETWEEN JOBS (include reason)

FIFTH TO LAST EMPLOYER COMPANY NAME:

MC#

ADDRESS:

CITY

STATE

ZIP

PHONE:

FAX:

E-MAIL:

CONTACT PERSON:

REASON FOR LEAVING?

JOB DESCRIPTION:

FROM:

TO:

CFR Part 40? YESNO *Was this job subject to FMCSA Regulations? YESNO
**ACCOUNT FOR PERIOD BETWEEN JOBS (include reason)

SIXTH TO LAST EMPLOYER COMPANY NAME:

MC#

ADDRESS:

CITY

STATE

ZIP

PHONE:

FAX:

E-MAIL:

CONTACT PERSON:

REASON FOR LEAVING?

JOB DESCRIPTION:

FROM:

TO:

CFR Part 40? YESNO *Was this job subject to FMCSA Regulations? YESNO
**ACCOUNT FOR PERIOD BETWEEN JOBS (include reason)

* The Federal Motor Carrier Safety Regulations 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 9 or more passengers, or 3) is of any size and is used to
transport hazardous materials in a requiring pleading.
** Any gaps in employment more than 30 days and/or unemployment must be explained.

Applicant Signature:

Date:


DISCLOSURE AND RELEASE FORM EMPLOYEE DRIVING RECORD INFORMATION

1. Because I must drive as an essential function of my employment or potential employment, I hereby give permission to
Global Expedited llc. to obtain my state driving record (also known as my motor vehicle record or MVR) in accordance with the Fair
Credit Reporting Act (FCRA) and the Federal Driver’s Privacy Protection Act (DPPA).
2. I acknowledge and understand that my driving record is a consumer report that contains public record information.
3. I authorize, without reservation any party or agency contacted by Global Expedited llc to furnish Global Expedited llc. a
copy of my state driving record.
4. I understand that I have the right to request a copy of my driving record and to know the source or sources of my driving
record, for a two-year period preceding my request.
5. This authorization shall remain on file by Global Expedited llc. for the duration of my employment, and will serve as
ongoing authorization for Global Expedited llc. to procure my state driving record at any time during my employment period.
6. I understand that Global Expedited llc. may take adverse action affecting my employment, based on information in my
driving record. If such adverse action is taken, I acknowledge that my rights are as follows:
● Employer must notify me in writing of any such adverse action
● I have the right to receive a copy of the driving record upon which the adverse action was based.
● I have the right to receive a summary of my rights under the Fair Credit Reporting Act. I have the right to know the name,
address and phone number of the consumer reporting agency that provided my driving record to Global Expedited llc.
● I have the right to obtain a free copy of my driving record from the agency that provided it, if such request is made
within 60 days from the date that Employer took adverse action.
● I have the right to dispute the accuracy or completeness of my driving record with the consumer reporting agency that
provided it, and request that errors be corrected.
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 interviews may result in
discharge. I understand, also, that I am required to abide by all rules and regulations of the Company.
I understand information I provide regarding current and/or previous employers may be used, and those employers 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 the 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.
This certifies 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.
In accordance with the provisions of Section 604 (b)(2)(A) of the Fair Credit Reporting Act, Public Law 91-508, as amended by
the Consumer Credit Reporting Act of 1996 (Title II, Subtitle D, Chapter I, of Public Law 104-208), you are being informed that reports
verifying your previous employment, previous drug and alcohol test results, and your driving record may be obtained on you for
employment purposes. Your employer may obtain this information from Equifax, TransUnion, Experian or other vendors of
information services

NAME

Signature

DATE

Social Security Number

Driver’s License Number & State

Date of Birth


PLEASE READ THE DISCLOSURE AND AUTHORIZATION STATEMENT PRIOR TO SIGNING THIS AUTHORIZATION FORM

I have carefully read and understood this Disclosure and Authorization Statement and the FTC summary of rights under the Fair Credit Reporting Act (“FCRA”). By my signature below, I consent to the release of consumer reports, investigative consumer reports, and other personal history reports prepared by a consumer reporting agency, government agency or department, or other entity to Global Expedited llc. (the “Company”). I understand that if the Company hires me, my consent will apply, and the company may obtain the 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. Furthermore, Customers of the Company may require investigative or consumer reports which apply to my background. These reports would apply to my assessment to projects related to the Customer, permission to be on the Customers premises and to handle its products and other security concerns of the Customer. I agree to allow the Company to provide my work history information to a consumer reporting agency. I understand that I have the right to review information provided by my previous employers, to have errors corrected by the previous employers and re-send to the Company once corrected, and to have a rebuttal statement attached to any alleged erroneous information should my previous employer and I not agree on the accuracy of the information. I further understand that the information provided by me will be used in making employment determinations and that my previous employer will be contacted for the purpose of investigating my safety performance history information as required by paragraphs (d) and (e) of “49 CFR” Part 391.23. Request to review previous employer information must be in writing. A release form for employment records can be requested by calling 630-283-8833, or mail to Safety Department, Global Expedited llc., 679 East South Frontage Road, Bolingbrook, IL 60440. I understand that I have additional rights under the FCRA as noted in the FTC summary of rights provided to me. I hereby authorize any person or company for whom I have worked (as an employee or contractor), whether listed below or not, to furnish information they may have pertaining to my character, habits, financial responsibility, job performance, reasons for leaving employment, and all information concerning my employment or training. I hereby release all persons and organizations from any claims from damages of any kind. By my signature below, I certify the information I provided on my application 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.

Previous Employer:

Printed name:

Signature:

Social Security Number:

Telephone number:

Signed date:


Request for employment verification

 

REQUEST FOR IMFORMATION FROM PREVIOUS EMPLOYER

From prospective employer:

Company:  Global Expedited LLC

Address: 679 East South Frontage RD

City, State, Zip: Bolingbrook, IL 60440

Phone: 630-283-8833

Fax: 630-755-2970

Company:

Address:

City, State, Zip:

Phone:

Fax:

Our applicant information:  ____________________________________

Name (first, last, middle): _____________________________________

Address: _________________________________________________

Social Security number: _______________________________________

CDL#, state: _______________________________________________

_______________________________*(name of applicant) has made application with us for a position as _______________________(position) and states that he/she was employed with ________________________________________(previous employer) as ____________________(previous position). We appreciate your time in completing the information requested herein. All information contained herein will be held in the strictest confidence. Thank You! - (name of requester and position) ______________________________.

PART 1 - general

Was this applicant employed with your company as stated above? [   ] Yes  [   ] No

If answered Yes, please provide employment period:   From: __________    To:____________

What kind(s) of work did the applicant do?  ______________________________________________

Did this applicant drive a commercial motor vehicle for your company?[   ] Yes  [   ] No

If answered YES what type?  [   ] Straight truck  [   ] Tractor-semi trailer  [   ] Bus  [   ] Other ___________

Was the applicant a safe and efficient driver? [   ] Yes  [   ] No

Was the applicant’s general conduct satisfactory?[   ] Yes  [   ] No

Is the applicant competent for the position sought?[   ] Yes  [   ] No

Did the applicant drink any alcoholic beverages while on duty?[   ] Yes  [   ] No

Reasons for leaving your employ?  [   ] Resignation    [   ] Discharged  [   ] Lay-off [   ] Other ___________

Would the applicant be eligible for rehire?[   ] Yes  [   ] No

If NO, please explain: _______________________________

Excellent Good Fair Poor Very Poor
Quality of work
Cooperation with others
Safety habits
Personal habits
Driving Skill
Attitude

PART 2 - driving record and accident history

Please indicate past three year history of driving record if available:      [   ] NOTHING TO REPORT

_________________________________________________________________________________________________

_________________________________________________________________________________________________

Accident record (if any)? Date/Type:                                                                                                        [   ] NOTHING TO REPORT

_________________________________________________________________________________________________

_________________________________________________________________________________________________

Remarks: _________________________________________________________________________________________

Request for employment verification

 


REQUEST FOR IMFORMATION FROM PREVIOUS EMPLOYER

PART3 - 49 CFR part 40 Drug and Alcohol testing

In the three years prior to the date of this request:

  1. Did the employee have an alcohol test with a result of 0.04 or higher? [   ] Yes  [   ] No  [   ] N/A
  2. Did the employee have verified positive test? [   ] Yes  [   ] No  [   ] N/A
  3. Did the employee refuse to be tested?                 [   ] Yes  [   ] No  [   ] N/A
  4. Did the employee have other violations of DOT agency, drug alcohol testing regulations? [ ] Yes  [   ] No  [   ] N/A
  5. Did a previous employer report a drug and alcohol rule violation to YOU? [ ] Yes  [   ] No  [   ] N/A
  6. If answered Yes to any of those questions, did the employee complete the return-to duty process? [ ] Yes  [   ] No  [   ] N/A

If you answered “YES” to question 5, you must provide the previous employer report.

If you answered “YES” to question 6, you must provide documentation for return-to-duty and any additional information (e.g. SAP report, follow-up testing records).:

SAP name:                 ___________________________________

SAP phone:                ___________________________________

SAP employer address: _________________________________

Name of person providing information:   _____________________

Title:  _____________________________________________

Phone Number:   _____________________________________

Date: _____________________________________________

In accordance with the provisions of Sections 604 and 607 of the Fair Credit Reporting Act, Public Law 91-508, as 104-208, I hereby certify the following:

1.Our applicant has authorized you, by signing on the bottom of this page, in writing to release this information;

2.Our applicant has been informed in a separate written disclosure that information from previous employer(s) may be obtained fro employment purposes;

3.The information requested below will be used for a “permissible purpose” (I.e. information for employment purposes) and will be used for no other purpose;

4.The information being obtained will not be used in violation of any federal or state equal opportunity law or regulation; and

5.Before taking an adverse action based in whole or in part on the report the consumer (applicant) will receive a copy of the requested report and the summary of the consumer rights as provided with report by the consumer agency

I Also hereby certify that this report request and the above applicant’s release notice meet the definition of “permissible uses” of state motor vehicle records under the provisions of the DRIVER’S PRIVACY ACT OF 1994 (Public Law No. 103-322, Title XXX, Section 300002(a))

Requester signature:  _______________________   

Date: _______________________

 

I hereby authorize release of information from my Department of Transportation regulated drug and alcohol testing records by:______________________________________________________(company name). This release is in accordance with DOT regulation 49 CFR Part 40, Section 40.25. I understand that information to be released from my previous employer is limited to the following DOT regulated testing items:

1. My general qualification(s) and employment history record.

2. Alcohol tests with a result of 0.04 or higher.

3. Verified positive drug tests.

4. Refusal to be tested.

5. Other Violations of DOT agency drug and alcohol testing regulations.

6. Information obtained from previous employers of a drug and alcohol violation.

7. Documentation, if any, of completion of the return-to-duty process following a rule violation.

Applicants signature:

   

Date:

              


THE BELOW DISCLOSURE AND AUTHORIZATION LANGUAGE IS FOR MANDATORY USE BY ALL
ACCOUNT HOLDERS

IMPORTANT DISCLOSURE
REGARDING BACKGROUND REPORTS FROM THE PSP Online Service

In connection with your application for employment with Global Expedited LLC. (“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 from FMCSA without your authorization.


AUTHORIZATION

If you agree that the Prospective Employer may obtain such background reports, please read the following and sign below:

I authorize Global Expedited LLC (“Prospective Employer”) to access the FMCSA Pre-Employment Screening Program (PSP) system to seek information regarding my commercial driving safety 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 challenge 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, I 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 Disclosure Regarding Background Reports provided to me by Prospective Employer and I understand that if I sign this Disclosure and Authorization, 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.

Date:

Signature

Name:

NOTICE: This form is made available to monthly account holders by NIC 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


Please upload the following documents:

Medical Card (required)

Drivers License (required)


Disclaimer: By checking the box below you agree and understand that the details given through this form are for the use of employment verification and for the purpose of applying for a position at our company. You understand and give us the authorization to use this information for those purposes and you understand that we must keep this information in our system between 3-6 years as per company records keeping policies. You are giving us authorization to distribute this information to third parties for the purpose of an employment verification.

I agree to the above stated and give this information willingly for the purpose of employment.
I AGREE