APPLICANT INFORMATION
Name
Email Address
Phone Number
Date of Birth
Address
Date Available For Hire
Have You Worked for Downey Trucking Before?
Are You Currently Employed?
Education (Years Completed)
If yes, please explain...
Conviction of a crime is not an automatic bar to employment. All circumstances will be considered.
PHYSICAL HISTORY
The Federal Motor Carrier Safety Regulations (49CFR391 Subpart E) requires that all driver applicants pass certain physical tests before they are hired to drive a motor vehicle.
ALCOHOL AND CONTROLLED SUBSTANCE STATEMENT
The Federal Motor Carrier Safety Regulations require all persons applying for a driving position requiring a commercial drivers license to answer the following questions:
DRIVER'S LICENSE INFORMATION
The past three years must be shown below...
1.) State (Current)
License Number (Current)
Type (Current)
Expiration Date (Current)
DRIVING EXPERIENCE
ACCIDENT HISTORY
The past three years must be shown below...
MOTOR VEHICLE DRIVING RECORD
Traffic Convictions and Forfeitures for the past 3 years other than parking violations...
EMPLOYMENT HISTORY
The Federal Motor Carrier Safely Regulalions (49CFR391.21) require that all applicants wishing to drive a commercial vehide list all employment for the last three (3) years. In addition, if you have driven a commercial vehicle previously, you must provide employment history for an additional seven (7) years for a total of ten (10) years. Any gaps in employment must be explained.
1.) Current or Most Recent Employer
Phone Number
From
To
Supervisor's Name
SIGNATURE
This is the description of your section break.
I understand Downey Trucking may contact me by phone to obtain sensitive information (Social Security Number) required for background checks, etc... YesNo
I have read the DISCLOSURE, AUTHORIZATION, and NOTICE below regarding background reports provided to me by Downey Trucking, and I understand that if I sign this Disclosure and Authorization, Downey Trucking may obtain a report of my crash and inspection history. I hereby authorize Downey Trucking and its employees, authorized agents, and/or affiliates to obtain the information authorized above. YesNo
Draw your signature into the box below.

DISCLOSURE
In connection with your application for employment with Downey Trucking, 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 Downey Trucking uses any information it obtains from FMCSA in a decision to not hire you or to make any other adverse employment decision regarding you, Downey Truckingr 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, Downey Trucking 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 Downey Trucking uses any information it obtains from FMCSA in a decision to not hire you or to make any other adverse employment decision regarding you, Downey Trucking 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 FM CSA; 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 Downey Trucking, who procured the report, then, within 3 business days of receiving your request, together with proper identification, Downey Trucking must send or provide to you a copy of your report and a summary of your rights under the Fair Credit Reporting Act.

Neither Downey Trucking 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, FMC SA 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 repo11. 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.

Downey Trucking cannot obtain background reports from FMCSA without your authorization.
I voluntarily give this institution the right to make a thorough investigation of my past employment and activities, agree to in such investigation and release this institution from all liability or responsibility all persons, companies or corporations supplying at such times and places as the institution shall designate. I understand that an offer of employment may be contingent on the physical examination which relates to essential duties I would be required to perform.

I understand my employment is at will, and that either party is free to terminate the employment relationship without cause. I also understand that my employment may be terminated for any misstatement or omission of fact appearing on this application form.

If employed, I will be required to complete an Employment Verification Form (I-9), and within three days show satisfactory verification of identity and eligibility of employment.

AUTHORIZATION
If you agree that Downey Trucking may obtain such background reports, please read the following:

I authorize Downey Trucking 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 Downey Trucking to make a determination rega

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 arc 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.

Last Updated: 12/22/2015