Application for Employment

Step 1 of 9 - APPLICATION FOR QUALIFICATION

APPLICATION FOR QUALIFICATION
Name*
First Last
Home Phone*
Mobile Phone*
Current Address*
Street Address City State / Province / Region ZIP / Postal Code Country
Duration of Residence*
How many year have you lived there?
Email Address*
Date of Birth*
Month
Day
Year
Social Security Number*
In Case of Emergency Notify:*
First Last
Emergency Contact's Phone Number*
Have you ever applied with this company before?*
- Yes
- No
If yes, when?*
Have you ever worked for this company under another name?*
- Yes
- No
If yes, what was your name?*
Are you currently employed?*
- Yes
- No
If not, how long since leaving your last employment?*
What date are you available to start work?*
MM slash DD slash YYYY
How long are you willing to be away from home?*
List states you operated in within the last 5 years*
List any safe driving awards and who presented them
How much home time will you need when you return from trips?*
How many miles or hours are you expecting per week?*
How much do you expect to make per week (gross)?*
Have you ever been convicted of a crime?*
- Yes
- No
(A conviction does not automatically bar you from employment)
If yes, please specify:*
1) Is it a conviction or pending charge? 2) Date of conviction or upcoming hearing? 3) Which state are you charged or convicted?
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EDUCATION
Highest level of education completed
Name of last school attended*
School's Address*
Street Address City State / Province / Region ZIP / Postal Code Country
List ANY special courses or training that will help you as a driver

Company	Years at this Position	Actions

There are no Jobs.

DRIVER EXPERIENCE & QUALIFICATION
LICENSES List all licenses held in the last 3 years.

Licenses

License Number Expiration Date Actions

There are no Licenses.

Maximum number of licenses reached.

Have you ever been denied a license, permit, or privilege to operate a motor vehicle?*

Yes

No
Has any license, permit, or privilege ever been suspended or revoked?*

Yes

No
Have you ever been disqualified for violations of the Federal Motor Carrier Safety Regulations (including Drugs & Alcohol violations)?*

Yes

No
If answered "Yes" to any of the above questions, please give details:*
ACCIDENT REVIEW
Please enter all accidents you have been in in the last 3 years.

License Number	Expiration Date	Actions

There are no Licenses.

Accidents in the last 3 years

Date Location Actions

There are no Accidents.

Maximum number of accidents reached.

MOTOR VEHICLE LAWS & ORDINANCES
Please enter any motor vehicle law & ordinance violations in the past 3 years.

Date	Location	Actions

There are no Accidents.

Violations

Location of violation Type of Charge Actions

There are no Violations.

Maximum number of violations reached.

DRIVER'S RIGHTS TO REVIEW BACKGROUND CHECK
Dear Applicant: Per FMCSR 391 .21 (d) Before an application is submitted, the motor carrier shall inform the applicant that the information he/she provides for the work history may be used, and the applicant's prior employers may be contacted, for the purpose of investigating the applicant's safety performance history information. The prospective motor carrier must also notify the driver in writing of his/her due process rights as specified in § 391.23(i) regarding information received as a result of these investigations. You the applicant have the following rights: (i) The right to review information provided by previous employers; (ii) The right to have errors in the information corrected by the previous employer and for that previous employer to re-send the corrected information to the prospective motor carrier; (iii) 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.
Applicant's Printed Name*
First Last
Applicant's eSignature*
Date*
Month
Day
Year
APPLICANT'S CONSENT STATEMENT
Applicant: Read and sign before submitting this application. It is agreed and understood that any misrepresentation given on this application shall be considered an act of dishonesty and reason for non-consideration or subsequent dismissal if hired or denial of authorization to drive. It is also agreed and understood that the motor carrier and his agents may investigate the applicant's background to ascertain any and all information of concern to applicant's record, whether same is of record or not, and applicant releases employers and persons named herein from all liability for any damages on account of his/her furnishing such information. I authorize the motor carrier to access the FMCSA Pre-Employment Screening Program (PSP) to seek information regarding my commercial driving safety record and information regarding my safety inspection history. I understand that I am consenting to 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 that nothing contained in this application or in the granting of an interview or a road test is intended to create an employment contract between this company and myself, for either employment, authorization to drive, or for the providing of any benefits. I agree to furnish such additional information that may be necessary and complete such examinations as may be required to complete my application file including but not limited to a pre-employment negative urine test and successful completion of a human performance evaluation including a Department of Transportation Physical. No promises regarding employment or authorization to drive have been made to me, and no such promises exist unless specifically made by this Company in writing. It is agreed and understood that if qualified, hired, or contract started, I may be on a probationary period during which time I may be disqualified without recourse. I understand employment or authorization to drive with this carrier is on an "at-will" basis that allows me to quit, be fired, or lease agreement revoked at any time with or without notice and with or without cause. 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.
Applicant's Printed Name*
First Last
Applicant's eSignature*
Date*
Month
Day
Year

Location of violation	Type of Charge	Actions

There are no Violations.

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DISCLOSURE STATEMENT
Applicant: Read and sign before submitting this application. By this document, Time Transport, Inc. discloses to you that a consumer report, including an investigative report containing information as to your character, general reputation, personal characteristics, driving record, and mode of living may be obtained as part of a background investigation as part of the Time Transport, Inc. 's driver qualification process. Should an investigative consumer report be requested you have the right to demand a complete and accurate disclosure of the nature and scope of the investigation requested and a written summary of your rights under the Fair Credit Reporting Act. Please sign below to signify receipt of the foregoing disclosure.
Applicant's Printed Name*
First Last
Applicant's eSignature*
Date*
Month
Day
Year

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PRE-EMPLOYMENT DRUG AND ALCOHOL TEST CONSENT FORM
I hereby give my full consent to submit to a substance abuse drug test in accordance with the requirements of the Federal Motor Carriers Safety Regulations, Title 49 CFRPart 40, and Time Transport, Inc.'s Drug and Alcohol Abuse Policy. I understand that all prospective drivers must submit to a substance abuse test and that a urine sample will be collected and tested for controlled substances. I give my full consent to the release of my substance abuse test results to the Time Transport, Inc. authorized Medical Review Officer(s) [MRO], who will them release the audited results to an authorized agent of Time Transport, Inc. I agree that if I test positive for use of controlled substances, or do not pass my physical examination/provide an unexpired Medical Certification, or disagree to sign a written authorization for the release of my past 3 years of drug test results, I will not be considered for employment by Time Transport, Inc. and/or may be terminated.
Applicant's Printed Name*
First Last
Applicant's eSignature*
Date*
Month
Day
Year

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MOTOR VEHICLE RECORD RELEASE AND AUTHORIZATION FORM
The undersigned does hereby authorize the release and delivery of all motor vehicle driving records relating to the undersigned, including but not limited to personal information, to my prospective or present employer and its insurance agent, whose names and addresses are as follows:

Employer:
Time Transport, Inc.
5231 U.S. 41
Franksville, WI 53126

Insurance Agent:
HNI Risk Services
16805 West Cleveland Avenue
New Berlin, WI 53151

This authorization shall continue in effect until revoked by the undersigned in a subsequent writing delivered to you.
Full Name*
First Last
Driver License Number*
Issuing State*
State

Date of Birth*
Month
Day
Year
Current Address*
Street Address City State / Province / Region ZIP / Postal Code Country

Signature
Date
MM slash DD slash YYYY

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IMPORTANT DISCLOSURE: BACKGROUND REPORTS FROM THE PSP ONLINE SERVICE
THE BELOW DISCLOSURE AND AUTHORIZATION LANGUAGE IS FOR MANDATORY USE BY ALL ACCOUNT HOLDERS
In connection with your application for employment with TIME TRANSPORT, 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 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 TIME TRANSPORT, INC. (“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.
Applicant's Printed Name*
First Last
Applicant's eSignature*
Date*
Month
Day
Year
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 2/11/2016

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APPLICANT'S DUE PROCESS RIGHTS NOTIFICATION
(i)(1) The prospective employer must expressly notify drivers with Department of Transportation regulated employment during the preceding three yearsvia the application form or other written document prior to any hiring decision-that he or she has the following rights regarding the investigative information that will be provided to the prospective employer pursuant to paragraphs (d) and (e) of this section:
(i)(1)(i) The right to review information provided by previous employers;

(i)(1)(ii) The right to have errors in the information corrected by the previous employer and for that previous employer to re-send the corrected information to the prospective employer;

(i)(1)(iii) 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.

(i)(2) Drivers who have previous Department of Transportation regulated employment history in the preceding three years, and wish to review previous employer-provided investigative information must submit 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. The prospective employer must provide this information to the applicant within five (5) business days of receiving the written request. If the prospective employer has not yet received the requested information from the previous employer(s), then the five-business days deadline will begin when the prospective employer receives the requested safety performance history information. If the driver has not arranged to pick up or receive the requested records within thirty (30) days of the prospective employer making them available, the prospective motor carrier may consider the driver to have waived his/her request to review the records.

(j)(1) Drivers wishing to request correction of erroneous information in records received pursuant to paragraph (i) of this section must send the request for the correction to the previous employer that provided the records to the prospective employer.

(j)(2) 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 a driver's request to correct the data that it does not agree to correct the data. If the previous employer corrects and forwards the data as requested, that employer must also retain the corrected information as part of the driver's safety performance history record and provide it to subsequent prospective employers when requests for this information are received. If the previous employer corrects the data and forwards it to the prospective motor carrier employer, there is no need to notify the driver.

(j)(3) Drivers wishing to rebut information in records received pursuant to paragraph (i) of this section must send the rebuttal to the previous employer with instructions to include the rebuttal in that driver's safety performance history.

(j)(4) After October 29, 2004, within five business days of receiving a rebuttal from a driver, the previous employer must:

(j)(4)(i) Forward a copy of the rebuttal to the prospective motor carrier employer;

(j)(4)(ii) Append the rebuttal to the driver's information in the carrier's appropriate file, to be included as part of the response for any subsequent investigating prospective employers for the duration of the three-year data retention requirement.

(j)(5) The driver may submit a rebuttal initially without a request for correction, or subsequent to a request for correction.

(j)(6) The driver may report failures of previous employers to correct information or include the driver's rebuttal as part of the safety performance information, to the FMCSA following procedures specified at §386.12.

(k)(1) The prospective motor carrier employer must use the information described in paragraphs (d) and (e) of this section only as part of deciding whether to hire the driver.

(k)(2) The prospective motor carrier employer, its agents, and insurers must take all precautions reasonably necessary to protect the records from disclosure to any person not directly involved in deciding whether to hire the driver. The prospective motor carrier employer may not provide any alcohol or controlled substances information to the prospective motor carrier employer's insurer.

(l)(1) No action or proceeding for defamation, invasion of privacy, or interference with a contract that is based on the furnishing or use of information in accordance with this section may be brought against

(l)(1)(i) A motor carrier investigating the information, described in paragraphs (d) and (e) of this section, of an individual under consideration for employment as a commercial motor vehicle driver,

(l)(1)(ii) A person who has provided such information; or

(l)(1 )(iii) The agents or insurers of a person described in paragraph (l)(1 )(i) or (ii) of this section, except insurers are not granted a limitation on liability for any alcohol and controlled substance information. with the procedures specified for these investigations.

(l)(2) The protections in paragraph (l)(1) of this section do not apply to persons who knowingly furnish false information, or who are not in compliance
Applicant's eSignature*
Date*
Month
Day
Year
Name
This field is for validation purposes and should be left unchanged.

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Step 1 of 9 - APPLICATION FOR QUALIFICATION

APPLICATION FOR QUALIFICATION

EDUCATION

EMPLOYMENT RECORD

Last Employer:

DRIVER EXPERIENCE & QUALIFICATION

ACCIDENT REVIEW

MOTOR VEHICLE LAWS & ORDINANCES

DRIVER'S RIGHTS TO REVIEW BACKGROUND CHECK

APPLICANT'S CONSENT STATEMENT

DISCLOSURE STATEMENT

PRE-EMPLOYMENT DRUG AND ALCOHOL TEST CONSENT FORM

MOTOR VEHICLE RECORD RELEASE AND AUTHORIZATION FORM

IMPORTANT DISCLOSURE: BACKGROUND REPORTS FROM THE PSP ONLINE SERVICE

AUTHORIZATION

APPLICANT'S DUE PROCESS RIGHTS NOTIFICATION

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