HOW TO APPLY New Waverly FAIR CREDIT REPORTING ACT DISCLOSURE STATEMENT

HOW TO APPLY
FAIR CREDIT REPORTING ACT DISCLOSURE STATEMENT
New
Waverly
TRANSPOR TATION
414 Union Street, Suite 2000, Nashville, TN 37219
902 Main Street S/E, Hanceville, AL 35077
Phone: (800) 494-3055, Fax: (866) 545-5457
The new wave in transportation.
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. These reports are required by Sections 382.413, 391.23,
and 391.25 of the The
Federal
Carrier Safety Regulations.
new waveMotor
in transportation.
Applicant Signature
Date
The new wave in transportation.
Print Name
Social Security Number
The new wave in transportation.
New
Waverly
TRANSPOR TATION
The new wave in transportation.
HOW TO APPLY
DISCLOSURE AND RELEASE
New
Waverly
TRANSPOR TATION
414 Union Street, Suite 2000, Nashville, TN 37219
902 Main Street S/E, Hanceville, AL 35077
Phone (800) 494-3055, Fax (866) 545-5457
The new wave in transportation.
In connection with my application for employment (including contract for services) with you, I understand that consumer
reports which may contain public records information may be requested from DAC Services, Tulsa, Oklahoma. These
reports may include the following types of information: names and dates of previous employers, reason for termination of
employment, work experience, accidents, etc. I further understand that such reports may contain public record information
concerning my driving
record,
compensation claims, credit, bankruptcy proceedings, criminal records, etc., from
The new
wave inworkers’
transportation.
federal, state and other agencies which maintain such records: as well as information from DAC concerning previous
driving record requests made by others from such state agencies, and state provided driving records.
I authorize, without reservation, any party or agency contacted by DAC to furnish the above–mentioned information.
I have the right to make a request to DAC, upon proper identification, to request the nature and substance of all
The new wave in transportation.
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 DAC has previously furnished within the two year period preceding my request. I hereby consent
to your obtaining the above information from DAC, and I agree that such information which DAC has or obtains, and my
employment history with you if I am hired, will be supplied by DAC to other companies that subscribe to DAC Services.
I hereby authorize procurement of consumer report(s). If hired (or contracted), this authorization shall remain on file
new wave in transportation.
and shall serve as The
ongoing
authorization for you to procure consumer reports at any time during my employment (or
contract) period.
New Waverly
Applicant Signature TRANSPOR TATION
Date
The new wave in transportation.
Print Name
Social Security Number
HOW TO APPLY
DRIVER’S APPLICATION FOR EMPLOYMENT
New
Waverly
TRANSPOR TATION
414 Union Street, Suite 2000, Nashville, TN 37219
902 Main Street S/E, Hanceville, AL 35077
Phone (800) 494-3055, Fax (866) 545-5457
The new wave in transportation.
In compliance with Federal and State equal employment opportunity laws, qualified applicants are considered for all
positions without regard to race, color, religion, sex, national origin, age, marital status, or non-job related disability.
(Answer ALL questions – PLEASE PRINT)
Date of Application
Position(s) Applied for?
Owner/Operator
The new wave in transportation.
Driver for: ______________________ Driver/Employee: ___________________________
Name
Social Security No.
Last
Phone
(
First
-
-
Middle
)
Alternate Phone (
)
List your addresses of residency for the past 3 years.
Current Address
The newStreet
wave in transportation.
Previous
Addresses
City
State
Zip
How long?
Street
City
State
Zip
How long?
Street
City
State
Zip
How long?
City
State
Zip
How long?
Street
The new wave in transportation.
Do you have the legal right to work in the United States?
Yes
Date of
Birth
No
/
/
(MM/DD/YYYY)
Have you worked for this company before?
Where?
Dates
From
New
Waverly
TRANSPOR TATION
To
The new wave in transportation.
Yes
No
Rate of Pay?
____ Position?
Reason for leaving?
Are you currently employed? Yes
Who referred you?
No
If No, how long since leaving last employment?
Rate of pay expected?
Have you ever been convicted of a felony? Yes__________ No_____________ If yes, please explain fully on a separate sheet of paper. Conviction of a
crime is not an automatic bar to employment – all circumstances will be considered.
Is there any reason you might be unable to perform the functions of the job for which you have applied? If yes, please explain.
EMPLOYMENT HISTORY
All applicants who drive a commercial motor vehicle in intrastate or interstate commerce shall provide TEN (10) years information on those employers
for whom the applicant has been associated.
Each blank MUST be complete and dates shall run consecutively. For any period of unemployment, applicant will list this as if it were any other job,
along with dates.
APPLICATIONS NOT COMPLETED CORRECTLY WILL NOT BE ACCEPTED!
Most Current Employer First
Employer
Start Date (month/year)
Address
End Date (month/year)
City
State
Zip
(
)
Area Code + Phone Number
Contact Person/Supervisor
Position
Reason for Leaving
WERE YOU SUBJECT TO THE FMCSR’s WHILE EMPLOYED? Yes _____ No ________ WAS YOUR JOB DESIGNATED AS A SAFETY-SENSITIVE FUNCTION IN ANY DOT-REGULATED MODE SUBJECT TO THE DRUG
AND ALCOHOL TESTING REQUIREMENTS OF 49 CFR PART 40? Yes______ No__________________________________________________________________________________________________________
Employer
Start Date (month/year)
Address
End Date (month/year)
City
State
Zip
(
)
Area Code + Phone Number
Contact Person/Supervisor
Position
Reason for Leaving
WERE YOU SUBJECT TO THE FMCSR’s WHILE EMPLOYED? Yes ____ No ____. WAS YOUR JOB DESIGNATED AS A SAFETY SENSITIVE FUNCTION IN ANY DOT-REGULATED MODE SUBJECT TO THE DRUG AND
ALCOHOL TESTING REQUIRED OF 49 CFR PART 40? Yes ______ No __________________________________________________________________________________________________________________
Employer
Start Date (month/year)
Address
End Date (month/year)
City
State
Zip
(
)
Area Code + Phone Number
Contact Person/Supervisor
Position
Reason for Leaving
WERE YOU SUBJECT TO THE FMCSR’s WHILE EMPLOYED? Use____ No____. WAS YOUR JOB DESIGNATED AS A SAFETY SENSITIVE FUNCTION IN ANY DOT-REGULATED MODE SUBJECT TO THE DRUG AND
ALCOHOL TESTING REQUIRED OF 49 CFR 40? Yes _____ No __________________________________________________________________________________________________________________________
Employer
Start Date (month/year)
Address
End Date (month/year)
City
State
Zip
Position
(
)
Contact Person/Supervisor
Area Code + Phone Number
Reason for Leaving
WERE YOU SUBJECT TO THE FMCSR’s WHILE EMPLOYED? Yes ____ No ____. WAS YOUR JOB DESIGNATED AS A SAFETY SENSITIVE FUNCTION IN ANY DOT-REGULATED MODE SUBJECT TO THE DRUG AND
ALCOHOL TESTING REQUIRED OF 49 CFR 40? Yes _____ No __________________________________________________________________________________________________________________________
Employer
Start Date (month/year)
Address
End Date (month/year)
City
State
Zip
Position
(
)
Contact Person/Supervisor
Area Code + Phone Number
Reason for Leaving
WERE YOU SUBJECT TO THE FMCSR’s WHILE EMPLOYED Yes ____ No ____. WAS YOUR JOB DESIGNATED AS A SAFETY SENSITIVE FUNCTION IN ANY DOT-REGULATED MODE SUBJECT TO THE DRUG AND
ALCOHOL TESTING REQUIRED OF 49 CFR 40? Yes ____ No ___________________________________________________________________________________________________________________________
Employer
Start Date (month/year)
Address
End Date (month/year)
City
State
Zip
Position
(
)
Contact Person/Supervisor
Area Code + Phone Number
Reason for Leaving
WERE YOU SUBJECT TO THE FMCSR’s WHILE EMPLOYED? Yes ____ No ____. WAS YOUR JOB DESIGNATED AS A SAFETY SENSITIVE FUNCTION IN ANY DOT-REGULATED MODE SUBJECT TO THE DRUG AND
ALCOHOL TESTING REQUIREMENTS OF 49 CFR 40 ? Yes _____ No _____________________________________________________________________________________________________________________
Employer
Start Date (month/year)
Address
End Date (month/year)
City
State
Zip
Position
(
)
Contact Person/Supervisor
Area Code + Phone Number
Reason for Leaving
WERE YOU SUBJECT TO THE FMCSR’s WHILE EMPLOYED? Yes ____ No _____. WAS YOUR JOB DESIGNATED AS A SAFETY SENSITIVE FUNCTION IN ANY DOT-REGULATED MODE SUBJECT TO THE DRUG AND
ALCOHOL TESTING REQUIREMENTS OF 49 CFE 40? Yes ____ No ______________________________________________________________________________________________________________________
ACCIDENTS
ACCIDENT RECORD FOR PAST THREE (3) YEARS (ATTACH SHEET IF MORE SPACE IS NEEDED) IF NONE, WRITE “NONE”
NATURE OF ACCIDENT
DATES
(head-on, rear-end, etc)
FATALITIES
INJURIES
TRAFFIC VIOLATIONS
TRAFFIC CONVICTIONS FOR THE PAST THREE (3) YEARS (OTHER THAN PARKING VIOLATIONS) IF NONE, WRITE “NONE”
LOCATION
DATE
CHARGE
PENALTY
EDUCATION
CIRCLE HIGHEST GRADE LEVEL COMPLETED 1 2 3 4 5 6 7 8 HIGH SCHOOL 1 2 3 4 COLLEGE 1 2 3 4
LAST SCHOOL ATTENDED
NAME OF SCHOOL
CITY, STATE
EXPERIENCE AND QUALIFICATIONS – DRIVER
STATE
LICENSE
NUMBER
EXPIRATION
DATE
TYPE
DRIVER’S
LICENSES
A.
B.
Have you ever been DENIED a license, permit or privilege to operate a motor vehicle?
Has any license, permit or privilege ever been suspended or revoked?
Yes
No
Yes
No
DRIVING EXPERIENCE
IF NONE, WRITE “NONE”
CLASS OF
EQUIPMENT
IF THE ANSWER TO EITHER A OR B IS YES, ATTACH STATEMENT GIVING DETAILS!
TYPE OF EQUIPMENT
(VAN, TANK, FLAT, ETC.)
TO
DATES
FROM
APPROXIMATE NUMBER OF
MILES (TOTAL)
Straight Truck
Tractor and Semi-Trailer
Tractor – Two Trailers
Motor Coach – School Bus
Other
List states operated in for last five (5) years
Show special courses or training that will help you as a driver
Which Safe Driving Awards do you hold and from whom?
EXPERIENCE AND QUALIFICATIONS – OTHER
List any trucking, transportation or other experience that may help in your work for this company
List any courses and training other than shown elsewhere in this application
List special equipment or technical materials you have experience working with (other than those already shown)
TO BE READ AND SIGNED BY APPLICANT
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, inquires 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 leasing my equipment or as a lease driver (employee of truck owner), I understand that false or misleading information
given in my application or interview(s) may result in discharge/cancellation of lease. I understand, also, that I am required to abide by all
rules and regulations of New Waverly Transportation and the Federal Motor Carrier Safety Regulations.
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 I have the right:
•
To review information provided by previous employers;
•
To have errors in the information corrected by the previous employer and for that previous employer to re-send corrected
information to the prospective employer;
•
To have a rebuttal statement attached to the alleged erroneous information, if the previous employer and the driver/applicant
cannot agree on the accuracy of the information.
Date
Applicant’s Signature
Social Security Number
Printed Name
TO BE READ AND SIGNED BY THE APPLICANT
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.
Signature: ________________________________________________________________________ Date: ________________
TO BE COMPLETED BY NEW WAVERLY TRANSPORTATION
PROCESS RECORD:
APPLICATION
PREVIOUS EMPLOYERS CHECKED
MVR CHECKED
ROAD TEST
D.O.T. DRUG TEST RESULTS
CHAIN OF CUSTODY FORM
D.O.T. PHYSICAL FORM
MEDICAL EXAMINERS CARD
DATE
RECEIVED BY
DATE
TRUCK NUMBER
DRIVER CELL NUMBER
CDL COPY
SOCIAL SECURITY COPY
ORIENTATION SCHEDULED
TIME
RECEIVED BY
/
/
TERMINATION OF EMPLOYMENT/LEASE AGREEMENT OR LEASE DRIVER
DATE TERMINATED: _______________________________________________ TERMINAL RELEASED FROM: __________________________
DISMISSED: __________________________ VOLUNTARILY QUIT: ______________________ OTHER: _______________________________
TERMINATION REPORT PLACED IN FILE: ___________________ COMPANY OFFICIAL: ___________________________________________
U.S. DOT Pre-Employment Screening Program
Driver Record Inquiry
New Waverly Transportation
414 Union Street Suite 2000
Nashville, TN 37219
Safety and Compliance / Phone 615-986-5705
Date
/
(PLEASE PRINT)
/
Applicant’s Name
Social Security #
Fax 866-545-5457
Last
First
Middle
Date of Birth
/
/
State
Driver’s License #
Signature - Driver
In accordance with DOT Regulations 391.23, I hereby authorize New Waverly Transportation
to obtain my driver record using the U. S. Department of Transportations Pre-Employment
Screening Program. By signing below, I certify that I fully understand that I execute this
authorization voluntarily and with the knowledge that the information obtained pursuant to
this authorization could affect my eligibility for leasing with New Waverly Transportation.
Prior to signing I was given an opportunity to ask questions and to have those questions
answered to my satisfaction.
To be completed by Owner
/
/
/
/
/
/
/
/
Signature- Truck Owner
Date
Faxed By
Date Faxed
Truck Number
Time Faxed
AM PM
To be completed by NWT, Inc.
Received @ NWT by
Date Received
Date Entered in DAC
Time Received
/
AM PM
/
Date Owner Notified
New Waverly Transportation, Inc. - 7 -