This form is required for all DOT governed drivers. It adheres to FMCSA’s requirements. Please fill it out truthfully and to your fullest ability.
L4Express Logistics Inc
215 Landers Way Covington, GA 30014
Phone #: (943) 230-1550
L4Express Logistics Inc is 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 and non-job related disabilities.
First Name:
Middle Name:
Last Name:
SSN:
Date of Birth
Street Address:
Street Address 2 (optional)
City:
CDL State —Please choose an option—ALAKAZARCACOCTDEFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWY
Zip
Home Phone #:
Cell Phone #:
Email:
Emergency Contact:
Relationship:
Emergency Phone #:
Have you ever been denied a license, permit or privilege to operate a motor vehicle? YESNO
Have any license, permit or privilege ever been suspended or revoked? YESNO
Application Date:
Position Applied For:
Who referred you?
Rate of pay expected:
Do you have the legal right to work in the United States? YESNO
Currently Employed? YESNO
If not, how long since leaving your last employment?
CDL #:
CDL Class:
CDL Expiration Date:
Have you ever tested positive or refused a DOT drug or alcohol pre employment test within the past 3 years from an employer who did not hire you? YESNO
Have you ever been convicted of a felony? YESNO
List All Addresses for previous 3 years:
Street
City
State —Please choose an option—ALAKAZARCACOCTDEFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWY
How Long
ADD ANOTHER ADDRESS YESNO
* You must list the last 10 years of employment history.
Employer/Lessor
Company Name:
Street:
Contact Person:
Phone #:
Fax #:
Were you subject to the FMCSRs* while employed? YESNO
From:
To:
Position:
Salary:
Reason for leaving:
Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirements. YESNO
Comments:
* The Federal Motor Carrier Safety Regulations (FMCSRs) 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 quantity requiring placarding.
Provide accident record, traffic convictions and forfeitures record for previous 3 years
Check box if no accidents in past 3 years
Date:
Location:
Fatalities:
Injuries:
Penalties:
Nature o Accident:
HAZARDOUS MATERIAL SPILL YESNO
TOW YESNO
ADD ANOTHER ACCIDENT YESNO
List all driver licenses or permits held in the past 3 years
License No.
Type:
Expiration Date:
ADD ANOTHER LICENSE YESNO
Class of Equipment:
Type of Equipment:
Date From:
Date To:
Approximately Number of Miles:
ADD ANOTHER EXPERIENCE YESNO
States Operated In For Last 5 Years:
Years of Experience:
School (Name, City, State)
Educational Level
Date From
Date To
Comments
ADD MORE YESNO
List any special training that will enable you to be a better driver:
List Any Safe Driving Awards You Have Earned:
Other Skills or Training:
I understand that in order to qualify for this position as an interstate commercial driver I must submit the employment controlled substance test, and must test negative before an offer of employment can be processed and is in accordance with US DOT Federal Motor Carrier Safety Regulations Part 391.I authorize L4Express Logistics Inc to make any such inquiries and investigations of my driving and past employment background, personal, financial and/or medical history, I hereby release state agencies, employers, schools, health care providers and/or any other person from all liability in connection to their responding to any and all inquiries from L4Express Logistics Inc and the subsequent release information to verify the accuracy of this application.I understand that in the event of my employment by L4Express Logistics Inc any false or misstatements given in my application or interview(s) may result in my discharge. I also understand that I have to abide by all rules and regulations of L4Express Logistics IncThis certifies that this application was completed by me, and that all entries on it and information in it is complete to the best of my knowledge.
Date of Application:
Signature:
In connection with my application for employment (including contract for services) with L4Express Logistics Inc
I understand that consumer reports which may contain public record information may be requested from DAC Services (DAC). These reports may include the following types of information: names and dates of previous employers, reason for termination, work experience, accidents, etc. I further understand that such reports may contain public record information concerning numbers of workers compensation history, credit, bankruptcy proceedings, criminal records, etc., from federal, state and other agencies providing such records; as well as information from DAC concerning previous driving record requests made by others from such state agencies that provided driving records. I AUTHORIZE, WITHOUT RESERVATION, ANY PARTY OR AGENCY CONTACTED BY DAC T ABOVE MENTIONED INFORMATION TO THE EXTENT AUTHORIZED BY STATE AND FEDERAL LAW.I have the right to make a request to DAC, upon proper identification, to request the nature and substance of all information in the time of my request, including the sources of information; and the recipients of any reports on me which DAC has previous the two year period preceding my request. I hereby consent to your obtaining the above information from DAC, and I agree that which DAC has or obtains, and my employment history with you if I am hired, will be supplied by DAC to other companies DAC Services.In conformity with 49 C.F.R. Part 40, I hereby authorize the carriers (Company/School) listed below to furnish to DAC on-behalf off listed above (Company), the following information concerning drug and alcohol tests: DOT drug and alcohol testing violations employment tests during the past two years: (I) the dates on which I tested positive for drugs and the drugs involved; (II) the results tested .04 or greater for alcohol and the test result level; (III) the dates on which I refused ( including a verified adulterated on to be tested for drugs and/or alcohol; (IV) and other violations of DOT drug and alcohol testing regulations; and (V) any information have received regarding violations of drug/alcohol testing regulations from my previous employers covered by DOT.I fully understand that the information I authorize DAC to receive involves tests which were required by the Department of T if any carrier (company/school) listed below furnishes DAC with information concerning items (I) trough (V) above, I also authorize (company/school) to release and furnish: (VI) the dates of my negative drug and/or alcohol tests and/or tests with results before two -year period; and (VII) the name and phone number of any substance abuse professional who evaluated me during the past.L4Express Logistics Inc
By signing below, I certify that I have read and fully understand this release that prior to signing I was given an opportunity to have those questions answered to my satisfaction, and that I executed this release voluntarily and with the knowledge that being released could affect my being hired. I further certify that all of the information that I have furnished on this form is true, and that I have listed every company for which I worked as a driver during the past two years, and every company for which I did drug and/or alcohol test during the past two years.
Social Security #:
Each driver shall furnish the list required in accordance with paragraph (a) of this section. If the driver has not been convictedof, or forfeited bond or collateral on account of, any violation which must be listed he/she shall so certify.
I certify that the following is a true and complete list of traffic violations (other than parking violations) for which I have been convicted or forfeited bond or collateral during the past 12 months.
Offense
Location
Type of Vehicle Operated
If no violations are listed above, I certify that I have not been convicted or forfeited bond or collateral on account of any violation required to be listed during the past 12 months.
DRIVER REQUIREMENTS Parts 383 and 391 of the Federal Motor Carrier Safety Regulations contain some requirements that you as a driver must comply with. These requirements are in effect as of July 1st, 1987. They are as follows:
1. You, as a commercial vehicle driver, may not posses more than one license. The only exception is if a state requires you to have more than one license. This exception is allowed until January I, 1990.
If you currently have more than one license, you should keep the license from your state of residence and return the additional licenses to the states that issued them. DESTROYING a license does not close the record in the state that issued it; you must notify the state. If a multiple license has been lost, stolen, or destroyed, you should close your record by notifying the state of issuance that you no longer want to be licensed by that state.
2. Sections 392.42 and 383.33 of the Federal Motor Carrier Safety Regulations require you to notify your employer the NEXT BUSINESS DAY of any revocation or suspension of your driver’s license. In addition, Section 383.31 requires that any time you violate a state or local traffic law (other than parking), you must report it to your employing motor carrier and the state that issued your license within 30 days.
DRIVER CERTIFICATION: I certify that I have read and understood the above requirements. The following license is the only one I will possess:
Driver’s Name:
Driver’s License #:
Exp. Date:
Yes, I want to buy insurance.No, I don't want to buy insurance.
IF YES: Please contact us for application.
IF NO: I am aware that it is my responsibility to provide work compensation insurance for myself. I also hold harmless L4Express Logistics Inc for work compensation benefits for myself.
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 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 Sec. 40.25(b)(5) and (e))
Have you ever been tested positive or refused to be tested on any pre-employment drug test in which you were not hired during the past two years? YESNO
If you answered YES, can you provide or obtain on our request proof that you have successfully completed the DOT return-to-duty requirements ? YESNO
Applicant’s Name:
I understand that as required by the Federal Motor Carrier Safety Regulations Title 49 United States Code of Federal Regulations Section 391,103, and company policy, all prospective drivers must submit to a controlled substances test. A urine sample will be collected and tested for controlled substances. I also understand that if test positive for use of controlled substances, I am not medically qualified to operate a commercial motor vehicie. The results of the drug test will be maintained by the Medical Review Officer or the company who will report whether the test results were negative or positive to the motor carrier. The results will not be released to any additional parties without my written authorization. I hereby agree to submit to a drug screen- urinalysis.
INSTRUCTIONS: When employed by a motor carrier, a driver must report to the carrier all on-duty time including time working for other employers. The definition of on-duty time found in Section 395.2 paragraphs (8) and (9) of the Federal Motor Carrier Safely Regulations includes time performing any other work in the capacity of, or in the employ or service of, a common, contractor private motor carrier, also performing any compensated work for any non motor carrier entity.
Are you currently working for another employer? YESNO
At this time do you intend to work for another employer while still employed by this company? YESNO
I hereby certify that the information given above is true and I understand that once I become employed with this company, if I begin working for any additional employer(s) for compensation that I must inform this company immediately of such employment activity.
INSTRUCTIONS: Motor carriers when using a driver for the first time shall obtain from the driver a signed statement giving the total time on-duty during the immediately preceding 7 days and time al which such driver was last relieved from duty prior to beginning work for such carrier. Rule 395.8(j)(2) Federal Motor Carrier Safety Regulations. NOTE: Hours for any compensated work during the preceding 7 days, including work for a non-motor carrier entity, must be recorded on this form.
Type of License:
Class:
Restrictions:
Endorsements:
Date: Hours:
Total Hours:
I hereby certify that the information given above is correct to the best of my knowledge and belief, and that I was last relieved from work at
Time:
In connection with your application for employment with L4Express Logistics 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 anysafety data that appears to be incorrect. You may challenge the accuracy of the data by submitting a request tohttps://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.
If you agree that the Prospective Employer may obtain such background reports, please read the following and sign below:
I authorize L4Express Logistics 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.
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.
In connection with your employment or owner-operator (independent contractor) application, L4Express Logistics Inc may order one or more consumer report(s) (commonly known as “background reports” or “background checks”) about you from one or more consumer reporting agencies. If you are hired or engaged as an owner-operator (independent contractor), additional consumer reports may be obtained in connection with and throughout your employment for employment purposes or for the legitimate business purpose of evaluating you as an owner-operator.
To the extent allowed by law, the consumer reports may include information concerning your character, general reputation, personal characteristics, mode of living, drug and alcohol test results, motor vehicle records, driving records, criminal history, public court records, employment history (including names and dates of previous employers, reason for termination of employment, work experience, and accidents), social security number validation, education, licensure, or verification of other information supplied by you. Such reports may be obtained from private and public record sources, including sanctions databases, CDLIS (including but not limited to CDLIS Central Site, CDLIS Master Pointer Record data and your driver record from the jurisdiction identified in the CDLIS data, in accordance with applicable state law and the Driver Privacy Protection Act), former employers, public court records, and federal, state, and other government agencies that maintain such records.
Printed Name:
| authorize L4Express Logistics Inc. to obtain one or more consumer report(s) or investigative consumer report(s) about me. If hired or engaged as an owner-operator (independent contractor), I understand this authorization shall remain on file and shall serve as ongoing authorization for additional consumer reports or investigative consumer reports to be obtained from any consumer reporting agency at any time during my employment or contract period without asking me for authorization again.
Employer / Contractor / Educational Institution:
L4Express Logistics Inc.
I hereby provide consent to L4Express Logistics Inc. to conduct a limited query of the FMCSA Commercial Driver’s License Drug and Alcohol Clearinghouse to determine whether drug or alcohol violation information about me exists in the Clearinghouse. I understand this consent shall remain on file and shall serve as ongoing consent for L4Express Logistics Inc. to conduct multiple limited queries of the Clearinghouse at any time during my employment or contract period without asking me for additional consent.
I understand that if I refuse to provide consent for L4Express Logistics Inc. to conduct a limited query of the Clearinghouse, L4Express Logistics Inc. is required to prohibit me from performing safety-sensitive functions, including operating a commercial motor vehicle.
I understand that if the limited query conducted by L4Express Logistics Inc indicated that drug or alcohol information exists about me in the Clearinghouse, the FMCSA will not disclose that information to L4Express Logistics Inc. unsless I give additional specific consent within the Clearinghouse. However, I understand that L4Express Logistics Inc. will be required to conduct a full query of the Clearinghouse within 24 hours after a limited query indicates that drug or alcohol information exists and that if I do not grant consent within the Clearinghouse for that full query I will be removed from performing safety-sensitive functions, including operating a commercial vehicle.
THIS FORM IS REQUIRED FOR OBTAINING YOUR MOTOR VEHICLE RECORDS. PLEASE COMPLETE THIS FORM ENTIRELY AND SIGN IT/DATE IT. YOUR MVR WILL BE ACCESSED BY L4EXPRESS LOGISTICS INC.
Social Security#:
Date of Birth:
Address(number, street):
Zip Code
CDL Expiration:
Drivers Signature:
INFORMATION MAY BE USED ONLY FOR THE FOLLOWING APPROVED DRIVER PRIVACY PROTECTION ACT(DPPA) PURPOSES. SELECT THE PURPOSE(S) FOR WHICH YOU WILL BE ORDERING MVRS:
– By a business that will use the information to verify the accuracy of information submitted by individuals for te purposes of preventing fraud, pursuing legal remedies against or recovering a debt or security interest.
– By an insurer or insurance support agency in connection with claims, investigations, antifraud, rating or underwriting.
– By an employer/agent or insurer to obtain or verify information on a Commercial License Holder.
– Written consent of the person whose record is being requested( Available in: AR,CA,CO,DC,FL,HI,IL,KY,MA,MN,NM,NY,ND,RI,VT,VA,WY)
Under the penalty of perjury, L4Express Logistics Inc. and its officers attest that they shall not obtain, resell, transfer, or use the information in any manner prohibited by law. L4Express Logistics Inc. and its officers understand that motor vehicle or driver records that are obtained, resold, or transferred for the purposes prohibited by law may subject L4Express Logistics Inc and its officers to civil penalties under federal and state law.
