Section 1: Personal Information

Addresses for the last 3 years:

Have you ever tested positive, or refused to test, on any pre-employment or other drug or alcohol test administered by an employer to which you applied for, but did not obtain, safety sensitive transportation work or that you were employed by who was covered by DOT agency drug and alcohol testing rules?*

Minimum Qualifications

• CDL Class “A” and be 23 years old or older
• 2 years verifable over-the-road tractor-trailer experience
• Current DOT physical
• Be able to successfully complete a drug and alcohol screening
• Be able to successfully pass a road test
• Must process a good track record of on-time deliveries and reliability
• Must have a steady work history averaging one year or more at jobs in the last four years
• No DUI, DWQL, reckless driving, or other major moving violations
• Less than two instances in a 12-month period (An instance is a moving violation or preventable accident)
• Less than three instances in any 36-month period
• No more than one preventable accident in any 36-month period

Section 2: Employment History

Section 3: Experience

List all your experience in the operation of motor vehicles (Reefer, Flatbed, 20', 40', 45', Straight Truck, etc.)

Section 4: Accidents

List ALL accidents involving a motor vehicle in the past three years. IF NONE, leave blank.

Section 5: Traffic Convictions

List ALL convictions for moving violations in the past three years. IF NONE, leave blank.

Section 6: Professional Information

Important Note: List ALL licenses held in the last three years.

1. Are you currently qualified to drive a commercial motor vehicle?*

   Yes

   No

2. Whithin the previous three years have you violated the alcohol and controlled substance prohibitions under Subpart B of 382 FMCSR or 49 CFE Part 40?*

   Yes

   No

3. Have you ever been convicted of a crime or narcotic offense?*

   Yes

   No

4. Has your license been suspended or revoked in the last five years?*

   Yes

   No

5. Have you ever been discharged for equipment abandonment?*

   Yes

   No

6. Have you ever left the scene of an accident?*

   Yes

   No

Section 8: Inquiry to Past Employer

You are hereby authorized to give TNG TRUCKING LLC all information regarding my services; character and conduct while in your employ, and you are released from liability that may result from giving such information. In order to comply with the requirements of 49 CFR, 382.413 & 391.23, I hereby consent to CT obtaining from my prior employers the information pertaining to me which they are required to maintain ny 49 CFR 382.401(b)(1)(I) through (III) regarding alcohol test with a concentration result of 0.04 or greater, positive controlled substances test results and hereby authorize and direct my prior employers to release such information to CT in personal interviews, telephone interviews, letters or any other method that insure confidentiality. I hereby authorize CT to release such information to any of its personnel whose duties require them to access this application or to make any recommendations or decisions with respect to it.

Section 9: Fair Credit Reporting Act Disclosure Statement

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 1966 (Title II, Subtitle D, Chapter 1, of Public Law 104-208), you are being informed that reports verifying your previous employment, previous drug and alcohol test results, and your driving records may be obtained on you for employment purposes. These reports are required by Section 382.413, 391.23, and 391.25 of the Federal Motor Carrier Safety Regulations.

Section 10: Driver's Rights Under FMCSR 391.23

As a driver, you are provided with certain rights under the Federal Motor Carrier Safety Regulations in Part 391.23. These rights are:

• 391.23(i)(1)
  
  • (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 employer;
  • (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.
• 391.23(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.
• 391.23(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.
• 391.23(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.
• 391.23(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.
• 391.23(j)(4)
  After October 29, 2004, within five business days of receiving a rebuttal from a driver, the previous employer must:
  • (i) Forward a copy of the rebuttal to the prospective motor carrier employer,
  • (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.
• 391.23(j)(5)
  The driver may submit a rebuttal initially without a request for correction, or subsequent to a request for correction.
• 391.23(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 Sec. 386.12.
• 391.23(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.
• 391.23(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.
• 391.23(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—
  • (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,
  • (ii) A person who has provided such information; or
  • (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.
• 391.23(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 with the procedures specified for these investigations.

I, the undersigned, have received a copy of, read, and understand the above mentioned rights.

The below disclosure and authorization language is for mandatory use by all account holders

Section 11: Important Disclosure Regarding background reports from the PSP Online Service

In connection with your application for employment with TNG Trucking 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.

Section 12: Authorization

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

I authorize TNG Trucking 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.

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

Section 13: Motor Vehicle Driver's Certification of Violations/Annual Review of Driving Record

MOTOR CARRIER INSTRUCTIONS: Each motor carrier shall at least once every 12 months, require each driver it employs to prepare and furish it with a list of all violations of motor vehicle traffic laws and ordinances (other than violations involving only parking) of which the driver has been convicted, or on account of which he/she has forfeited bond or collateral during the preceding 12 months (Section 391.27). Drivers who have provided information required by Section 383.31 need not repeat that information on this form.

DRIVER REQUIREMENTS: Each driver shall furnish the list as required by the motor carrier above. If the driver has not been convicted of, or forfeited bond or collateral on account of any violation which must be listed, he/she shall so certify (Section 391.27).

Completed by Driver—Certification of Violations

I certify that the following is a true and complete list of traffic violations required to be listed (other than those I have provided under Part 383) for which I have been convicted or forfeited bond or collateral during the past 12 months.

If you have had no violations, check the following box:

If no violations are listed above, I certify that I have not been convicted or forfeited bond or collateral on account of any violation (other than those I have provided under Part 383) required to be listed during the past 12 months.

Section 14: Pre-Employment Background Check — Disclosure and Release Form

In connection with my application for employment (including contract for services as an independent contractor) with you. I understand that consumer reports which may contain public record information may be requested from a “consumer reporting agency” (CRA's). These reports may include the following types of information: names and dates of previous employers, reason for termination of employment, work experience, accidents and information on drug and alcohol test results and problems, if any. I further understand that such reports may contain public record information concerning my driving records, workers' compensation claims, credit, bankruptcy proceedings, criminal records, etc., from federal, state, and other agencies which maintain such records; as well as information from CRAs concerning previous driving record requests made by others from such state agencies and state provided driving records.

I authorize, without any reservations, any party or agency contacted by a CRA to furnish the above-mentioned information.

I have the right to make a request to the CRA upon proper identification, to request the nature and substance or all information in its files on me at the time of my request, including the sources of information, and the recipients of any reports on me, which the CRA has previously furnished within the two year period preceding my request. I hereby consent to your obtaining the above information from a CRA and I agree that such information which CRA has or obtains, and my employment history with you if I am hired, will be supplied by a CRA to other companies that subscribe to a CRA service.

I have read and understand the summary of my rights under the Fair Credit Reporting Act attached to this release. Signature below denotes my acceptance and understanding of this summary.

I hereby authorize procurement of consumer report(s). If hired (or contracted), this authorization shall remain on file and shall serve as ongoing authorizations for you to procure consumer reports at any time during my employment (or contract) period.

Section 15: Previous Pre-employment Employee Alcohol and Drug Test Statement

Sec. 40.25(j) As the employer, you must also ask the employee whether he or she has tested positive, or refused to test, on any pre-employment drug or alcohol test administered by an employer to which the employee applied for, but did not obtain, safety-sensitive transportation work covered by DOT agency drug and alcohol testing rules during the past two years. If the employee admits that he or she had a positive test or a refusal to test, you must not use the employee to perform safety-sensitive functions for you, until and unless the employee documents successful completion of the return-to-duty process (see paragraphs (b)(5) and (e) of this section).

Prospective Employee Information:

The prospective employee is required by Sec. 40.25(j) to respond to the following questions.

1. Have you tested positive, or refused to test, on any pre-employment drug or alcohol test administered by an employer to which you applied for, but did not obtain, safety-sensitive transportation work covered by DOT agency drug and alcohol testing rules during the past two years?*

   Yes

   No

2. If you answered yes, can you provide/obtain proof that you've successfully completed the DOT return to duty requirements?

   Yes

   No

I certify that the information provided on this document is true and correct.