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BARROW LOGISTICS
2100 N HWY 360 # # 900B • GRAND PRAIRIE, TX 75050 (214) 235-0057 • Fax (469) 986-0248 Web Address: www.nomadxs.com AN EQUAL OPPORTUNITY/AT WILL EMPLOYER NOTICE TO ALL APPLICANTS: Screening tests for alcohol and illegal drug use required before hiring and during your employment. Please answer all questions completely. Print in ink or type. Resumes may be attached with a completed application. A resume does not take the place of an application. Failure to comply with all instructions will result in disqualification. NOTE: DUE TO THE VOLUME OF APPLICANTS, WE ARE UNABLE TO RESPOND TO THE STATUS OF EACH APPLICATION.
In compliance with Federal and state equal opportunity laws, qualified applicants are considered for all positions without regard to race, religion, sex national origin, age marital status, or non-job-related disability. Please answer all questions. If the answer to any question is “No” or “None”, do not leave item blank, but write “No” or “None”
Personal Details
Last Name
First Name
MI
SSN
DOB
DOB
City/State/Zip
Address
City
State
Zip Code
Previous Address
Address
City
State
Zip Code
Address
City
State
Zip Code
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General Questions
Positions Applied For
Full Time
Full Time
Part Time
Temporary
Who Referred You
Name
Rate Of Pay Expected
Have you worked here before
Yes
No
If yes?
From
To
Location
Position
Rate
Why left
Names of any relatives employed by the company:
Are you employed now
Yes
No
If no, how long since leaving last employment?
Are you legally qualified to work in this country?
Yes
No
Ever convicted?
Have you ever been convicted of a felony?
Yes
No
If yes explain:
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Education
Type of school (Elm, High, Tech, College)
Name of Institution(s)
City and State
Highest Grade Completed or Degree Earned
Type of school (Elm, High, Tech, College)
Name of Institution(s)
City and State
Highest Grade Completed or Degree Earned
Type of school (Elm, High, Tech, College)
Name of Institution(s)
City and State
Highest Grade Completed or Degree Earned
Driver License
Driver License State
License Number
Expiration Date
Type or class of license
Endorsements
Driver License State
License Number
Expiration Date
Type or class of license
Endorsements
Driver License State
License Number
Expiration Date
Type or class of license
Endorsements
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Tractor /Trailer
Equipment operated
Equipment type (please specify)
# of years experience
Approximate number of miles driven(total)
Straight truck
Equipment operated
Equipment type (please specify)
# of years experience
Approximate number of miles driven(total)
Bus
Equipment operated
Equipment type (please specify)
# of years experience
Approximate number of miles driven(total)
Other
Equipment operated
Equipment type (please specify)
# of years experience
Approximate number of miles driven(total)
ACCIDENTS
Accidents date (starting with most recent)
Nature of accident (passenger vehicle, head-on, rear-end, etc)
Injury/ Fatality
Comments
Accidents date (starting with most recent)
Nature of accident (passenger vehicle, head-on, rear-end, etc)
Injury/ Fatality
Comments
Accidents date (starting with most recent)
Nature of accident (passenger vehicle, head-on, rear-end, etc)
Injury/ Fatality
Comments
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TRAFFIC CONVICTION
Conviction date
Location(State)
Charge
Penalty
Conviction date
Location(State)
Charge
Penalty
Conviction date
Location(State)
Charge
Penalty
Have you ever been denied a license, permit, or permillage operate a motor vehicle?
Yes
No
Have you ever had a license, permit, or permillage to operate ever suspended or revoked?
Yes
No
If yes explain:
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All driver applicants must provide the following information on all work references during the preceding (3) years from the date the application is submitted. Those drivers applying to operate a commercial motor vehicles as defined in &383.5(requiring a CDL) shall provide 10 years of employment history. NOTE: Please list companies in reverse order starting with most recent and leave no gaps in employment history. Please request additional sheets if necessary.
Company Name
Address
Address
City
State
Zip Code
Contacts
Name
Phone Number
Employed From
Employed from:
Employed To:
Total Month/Years
Position(s) Held
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Subjected to FMCSR
Yes
No, Were you subjected to Federal Motor Safety Regulations while employed by Employer
Yes
No, Was this job designated as safety sensitive in any DOT regulated mode subject to alcohol and controlled substance testing requirement as required by 48 CFR part 40?
Reason for leaving
Resignation
Lay off
Terminated
Others Please describe
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Company Name
Address
Address
City
State
Zip Code
Contacts
Name
Phone Number
Employed From
Employed from:
Employed To:
Total Month/Years
Position(s) Held
Subjected to FMCSR
Yes
No, Were you subjected to Federal Motor Safety Regulations while employed by Employer
Yes
No, Was this job designated as safety sensitive in any DOT regulated mode subject to alcohol and controlled substance testing requirement as required by 48 CFR part 40?
Reason for leaving
Resignation
Lay off
Terminated
Others Please describe
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Company Name
Address
Address
City
State
Zip Code
Contacts
Name
Phone Number
Employed From
Employed from:
Employed To:
Total Month/Years
Position(s) Held
Subjected to FMCSR
Yes
No, Were you subjected to Federal Motor Safety Regulations while employed by Employer
Yes
No, Was this job designated as safety sensitive in any DOT regulated mode subject to alcohol and controlled substance testing requirement as required by 48 CFR part 40?
Reason for leaving
Resignation
Lay off
Terminated
Others Please describe
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Company Name
Address
Address
City
State
Zip Code
Contacts
Name
Phone Number
Employed From
Employed from:
Employed To:
Total Month/Years
Position(s) Held
Subjected to FMCSR
Yes
No, Were you subjected to Federal Motor Safety Regulations while employed by Employer
Yes
No, Was this job designated as safety sensitive in any DOT regulated mode subject to alcohol and controlled substance testing requirement as required by 48 CFR part 40?
Reason for leaving
Resignation
Lay off
Terminated
Others Please describe
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Company Name
Address
Address
City
State
Zip Code
Contacts
Name
Phone Number
Employed From
Employed from:
Employed To:
Total Month/Years
Position(s) Held
Subjected to FMCSR
Yes
No, Were you subjected to Federal Motor Safety Regulations while employed by Employer
Yes
No, Was this job designated as safety sensitive in any DOT regulated mode subject to alcohol and controlled substance testing requirement as required by 48 CFR part 40?
Reason for leaving
Resignation
Lay off
Terminated
Others Please describe
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Company Name
Address
Address
City
State
Zip Code
Contacts
Name
Phone Number
Employed From
Employed from:
Employed To:
Total Month/Years
Position(s) Held
Subjected to FMCSR
Yes
No, Were you subjected to Federal Motor Safety Regulations while employed by Employer
Yes
No, Was this job designated as safety sensitive in any DOT regulated mode subject to alcohol and controlled substance testing requirement as required by 48 CFR part 40?
Reason for leaving
Resignation
Lay off
Terminated
Others Please describe
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SAFETY PERFORMANCE HISTORY INVESTIGATION - PREVIOUS US DOT REGULATED EMPLOYERS
Please complete one form for each previous USDOT regulated employer within previous three (3) year
DRIVER APPLICANT RELEASE
I hereby authorize you to release the following information to BARROW LOGISTICS and their agents for the purpose of investigation as required by &391.23 and & 40.321(b) of the Federal Motor Carrier Safety Regulations. You are hereby released form any and all liability which may result from furnishing such information
Applicant signature
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Applicant Date
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Previous Address
Last Name
First Name
MI
SSN
City/State/Zip
PREVIOUS EMPLOYER/COMPANY NAME
Address
City
State
Zip Code
Employed from:
Employed To:
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CERTIFICATE OF VIALOTION - ANNUAL REVIEW OF DRIVER RECORD
PREVIOUS EMPLOYER: in accordance with 49 CFR 40.25 and 391.23, we are hereby requesting you supply us with the safety performance history of this individual. under DOT rule 391.23(g), you must respond to this enquiry within 30 days of receipt.
Yes:- Are the dates of employment correct as stated above?
If no, Please provide the correct dates of employment
Employment Date
Yes:- Did the applicant drive commercial motor vehicle for your company ?
No
Yes:- Was the applicant safe and efficient driver?
No
Yes:- Was the applicant involved in any vehicle accidents while employed with your company?
No
Resignation
Desicharged
Lay off: Reason for leaving your Employment
Yes:- Has the applicant test positive for control substance in the last three (3) years?
No
Yes:- Has the applicant had an alcohol with a B.A.C of 0.04 or greater in the last three (3) years ?
No
Yes:- Has the applicant refused a required test drugs or alcohol in the last three (3) years?
No
Yes:- Did the applicant complete a substance abuse rehabilitation program if required
No
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Yes:- Has the person ever violated other DOT agency drug and alcohol testing regulations?
No
Print Name
Title
Applicant signature
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Date
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For driver applicants of commercial motor vehicles that require a Commercial Driver License (CDL) the applicant must disclose their controlled substance and alcohol status per the requirements of 49 CFR part 40.25(j). As a prospective driver employee, you have the right to review information provided by previous employers. You have the right to have errors in the information corrected by the previous employer(s) and for that previous employer(s) to re-send the corrected information to the prospective employer; 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. Driver employees 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 thirty (30) days after being
CERTIFICATE OF VIALOTION - ANNUAL REVIEW OF DRIVER RECORD
MOTOR CARRIER REQUIREMENT Each motor Carrier shall at least once every twelve(12) months , require each driver it employs to prepare and furnish it with a list of all violation of motor vehicle traffic laws and ordinance, (other than parking violations) of which the driver has been convicted or on account of which he/she has forfeited bond or collateral during the preceding 12 months (&391.27)
CERTIFICATE OF VIOLATION (completed by driver/applicant)
Applicant Name
SSN
Driver's license No
Driver's license state
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I certify that the following is true and complete list of traffic violation (other than parking violation) for which I have been convicted or forfeited bond or collateral during the pat 12 months
Violations are listed below
I have no violations
VIOLATIONS
Dates
Offense
Locations
Type of vehicle operated
Dates
Offense
Locations
Type of vehicle operated
Dates
Offense
Locations
Type of vehicle operated
Dates
Offense
Locations
Type of vehicle operated
Applicant signature
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Applicant Date
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ANNUAL REVIEW OF DRIVING RECORD (completed by motor carrier)
I have hereby reviewed the record of the above name driver in accordance with &391.25 find that he/she:
Meets Minimum requirement for safe driving
Is disqualified to drive a motor vehicle pursuant to &391.15
Does not adequately meet satisfactory safe driving performance
Action taken with the driver:
Applicant signature
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Applicant Date
Print Name
Title
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REQUEST FOR CHECK OF DRIVING RECORDS DRIVER APPLICANT I here by authorize you to release the following information to BARROW LOGISTICS and their agents for the purpose of investigation as required by &391.23 and &391.25 of the Federal Motor Carrier safety Regulation. If hired, I authorize an annual check of my motor vehicle records required by &391.25 of the Federal Motor Carrier safety Regulation. You are here by released from any and all liability which may result in furnishing such information.
Applicant signature
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Applicant Date
MOTOR CARRIER In accordance with the provision of section 604 and 607 of the fair credit act. Public law 51-908 as as amended by the consumer credit report act of 1996 (Title II and sub title D, Chapter of public Law 104-208. I hereby certify the following 1) The consumer (applicant) has authorized in writing the procurement of this report 2) The consumer (applicant) has been informed in separate written disclosure that a consumer report may be obtained for employment purpose 3) The information requested below will be used for a “permissible purpose” (i.e. information for employment purpose) and will be used for no other purpose 4) The information being obtained will not be used in violation of federal or state equal opportunity law or regulation and; 5) Before tacking an adverse action based on a whole or part on the report the consumer (applicant) will receive a copy of the requested report and the summary of consumer rights as provided with report by the consumer reporting agency. I also hereby certify that this report requested and the above applicant’s release notice meet the definition or “permissible uses” of state motor vehicle records under the provisions of the Drivers’ privacy protection act of 1994 (Public Law 103-322, Title XXX, Section 300002(a))
Requester's signature
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Requester's Date
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Requester's Name
Requester's Company
Requester's Address, City, State & Zip
 The following named person has made application with our company for the position of ______________________. In accordance with &391.23 of the U. S Department of Transportation Regulations, please furnace the above signed with applicant’s driving records for the past three (3) years.  The following named person I employed with our company in the position of ________________________. In accordance with &391.23 of the U. S Department of Transportation Regulations, please furnace the above signed with applicant’s driving records for the past years.
Personal Details
Last Name
First Name
MI
SSN
DOB
DOB
City/State/Zip
Address
City
State
Zip Code
Previous Address
Address
City
State
Zip Code
Driver's License No
Driver's License State
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CERTIFICATION OF COMPLIANCE WITH DRIVER LICENSE REQUIREMENTS MOTOR CARRIER REQUIREMENTS
MOTOR CARRIER INSTRUCTIONS: The requirements in Part 383 apply to every driver who operates in intrastate, interstate, or foreign commerce and operates a vehicle weighing 26,001 pounds or more, can transport more than 15 people, or transports hazardous materials that require placarding. The requirements in Part 391 apply to every driver who operates in interstate commerce and operates a vehicle weighing 10,001 pounds or, can transport more than 15 people, or transports hazardous materials that require placarding. 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 1, 1987. They are as follows: 1 POSSESS ONLY ONE LICENSE: you, as a commercial vehicle driver, may not possess more than one motor vehicle operator's license. If you have more than one license, 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, close your record by notifying the state of issuance that you no longer want to be licensed by that state. 2 NOTIFICATION OF LICENSE SUSPENSION, REVOCATION OR CANCELLATION: Sections 391.5 (b)(2) and 383.33 of the Federal Motor Carrier Safety Regulations required that you 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 within 30 days to your employing motor carrier, and the state that issued your license (if the violation occurs in a state other than the one which issued your licensed). The notification to both the employer and state must be in writing. The following license is the only one I will possess:
Driver's License No
Driver's License State
Expiration Date
Expiration Date
Driver's Name
DRIVER CERTIFICATION: I certify that I have read and understood the above requirements.
Applicant signature
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Applicant Date
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THE BELOW DISCLOSURE AND AUTII01?1ZATION LANGUAGE IS FOR MANDATORY USE BY ALL ACCOUNT HOLDERS
Drivers Statement of On-Duty Hours (To be completed upon hire) 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 at 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.
DRIVER/ APPLICANT
Applicant Name
SSN
Driver's license No
Driver's license state
Class
Endorsement
Restriction(s)
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Hours worked
Day 1
Day 1 Hours
Day 2
Day 2 Hours
Day 3
Day 3 Hours
Day 4
Day 4 Hours
Day 5
Day 5 Hours
Day 6
Day 6 Hours
Day 7
Day 7 Hours
I hereby Certify, the following information given is correct to the best of my knowledge and belief , and that I was relived from work at:
Relieved
Time AM/PM
Date
Date
Applicant signature
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Applicant Date
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DRIVER CERTIFICATION FOR OTHER COMPENSATED WORK
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 Safety Regulations includes time performing any other work in the capacity of, or in the employ or service of, a common, contract or private motor carrier, and performing any compensated work for any non-motor carrier entity
Yes
No, Are you currently working for another employer?
Yes
No, At this time do you intend to work for another employer while still employed by this company?
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.
Applicant signature
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Applicant Date
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Witness/Company Representative
Requester's Date
PREVIOUS PRE-EMPLOYEMENT CONTROLLED SUBSTANCES AND ALCOHOL TEST DESCLOSURE
The following question is made necessary for employment with BARROW LOGISTICS by the Federal Motor Carrier regulation, Section 40.25 Have you ever 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 I have
Yes I have
If you answered yes to the above question, can you provide proof that you have successfully completed the DOT return-to-duty requirements? Alongside with the Agency Name
Substance Abuse Professional:
Phone:
Return To Duty Test
Yes I have
No I have not
Applicant (please print)
Reviewed Signature
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Applicant Date
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If you answered yes to the above question, please request consent for release of information regarding previous pre-employment controlled substance or alcohol testing form
CONTROLLED SUBSTANCES AND ALCOHOL TESTING CONSENT FORM
The following question is made necessary for employment with BARROW LOGISTICS by the Federal Motor Carrier regulation, Section 40.25 Have you ever 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?
I also understand that it is a condition of being considered for employment and continued employment by the company that I agree abide by the company policy. By my signature I consent to urine and/or breath/saliva testing for controlled substances and/or alcohol prior to and any time during my employment when requested by my employer on random or event triggered basis. I hereby specifically authorize the company to have all and immediate access to any and all urine and/or breath/saliva custody and control forms and the result thereof. I understand and agree that I may not be under any degree of influence of alcohol or controlled substance at any time during my employment. Should any level of alcohol or controlled substance in any of my breath, saliva or urine at any time while employed. The company shall have grounds for immediate termination of my employment. This authorization specifically covers any random or event triggered testing as may be required by U.S. Department of Regulation or company policy.
Reviewed Signature
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Applicant Date
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CONTROLLED SUBSTANCES AND ALCOHOL TESTING POLICY RECEIPT
I, (applicant) ______________________________________________________ have received a copy of controlled substance and alcohol testing policy for BARROW LOGISTICS. By my signature, I acknowledge that I have read, understand, and consent to this policy.
Reviewed Signature
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Applicant Date
APPLICATION CERTIFICATE This certifies that this application was by me, and that all entries on it and information in it are true and complete to my best knowledge.
Reviewed Signature
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Applicant Date
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THE BELOW DISCLOSURE AND AUTII01?1ZATION LANGUAGE IS FOR MANDATORY USE BY ALL ACCOUNT HOLDERS IMPORTANT DISCLOSURE REGARDING BACKGROUND REPORTS FROM THE PSP Online Service
In connection with your application for employment with BARROW LOGISTICS ("Prospective Employer"), Prospective Employer, its employees, agents or contractors may obtain one or more reports regarding our 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 Data Qs 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 BARROW LOGISTICS ("Prospective Employer") to access the FMCSA Pre-Employment Screening Program (PSP) system to seek information regarding my commercial driving safety record and information egarding 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 Data Qs 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 I have read the above Disclosure Regarding Background Reports provided to me by Prospective Employer and I understand that it 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.
Reviewed Signature
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Applicant Date
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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 12/22/2015
Current Driver's License A copy of a current, valid license is required per §383.23(a), §391.11(b)(5), and §391,33 of the Federal Motor Carrier Safety Regulations. Please make copies of the front and back of your current driver's license and attach below. NOTICE: The prospective employment concept referenced in this form contemplates the definition of "employee" contained at 49 C.F.R. 383.5. LAST UPDATED 12/22/2015
Current Driver's License A copy of a current, valid license is required per §383.23(a), §391.11(b)(5), and §391,33 of the Federal Motor Carrier Safety Regulations. Please make copies of the front and back of your current driver's license and attach below. NOTICE: The prospective employment concept referenced in this form contemplates the definition of "employee" contained at 49 C.F.R. 383.5. LAST UPDATED 12/22/2015
Upload Front and Back Of Driver License
Motor Carrier Medical Examiners National Registry Verification BARROW LOGISTICS 2100 N Hwy 360 Suite 900B Grand Prairie, TX 75050 CFR 391.51 — General Requirements for a Driver Qualification File (b)(9): A note relating to verification of listing in the National Registry of Certified Medical Examiners required by CFR 391,23(m).
Upload Medical Card
Motor Carrier Verification
Driver's Name (print)
Medical Examiner Name:
Medical Examiner National Registry Number:
Verification made by:
Applicant Date
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