Driver Application « Ballard, Inc. Trucking

APPLICANT INFORMATION

Name*

First Last

M.I.

DOB*

Street Address*

Apartment/Unit #

City*

State*

ZIP*

Home Phone

Cell Phone*

Date Available

Social Security No.

Desired Salery

Position Applied for

Are you a citizen of the United States?*

Are you authorized to work in the U.S.?*

Have you ever had a positive result or refusal to test on a DOT drug/alcohol test?*

Explain*

Have you ever been convicted of a felony?*

Explain*

Emergency Contact Name & Phone*

License State & Number*

Years of CDL Exp?*

License Exp. Date*

License Class & Endorsements*

Medical Exam Cert. Due Date*

How did you hear about us?*

PREVIOUS EMPLOYMENT

Company #1

Phone

Job Title

Address

From

To

Reason for Leaving

Company #2

Phone

Job Title

Address

From

To

Reason for Leaving

Company #3

Phone

Job Title

Address

From

To

Reason for Leaving

DISCLAIMER AND SIGNATURE

I certify that my answers are true and complete to the best of my knowledge. If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release.

Electronic Signature*

Please type your First and Last Name

*

I understand that checking this box constitutes a legal signature confirming that I acknowledge and agree to the above Terms of Acceptance

Date*

Application Release Forms

Applicant's Name*

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, veteran status, non-job related disability, or any other protected group status.

FAIR CREDIT REPORTING ACT DISCLOSURE STATEMENT

In accordance with the Fair Credit Reporting Act (FCRA), 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), [Institution’s Name] may obtain a consumer report (commonly known as a background report) and/or an investigative consumer report from a consumer reporting agency for employment purposes.

These reports may include information concerning your employment history, education, qualifications, character, general reputation, personal characteristics, criminal record, motor vehicle record, mode of living, credit standing, and/or indebtedness. This information may be obtained from public and/or private sources. Additionally, reports verifying your previous employment, previous drug and alcohol test results, and your driving record may be obtained as required by Sections 382.413, 391.23, and 391.25 of the Federal Motor Carrier Safety Regulations.

A consumer report and/or an investigative consumer report may be obtained during the hiring process or at any time during your employment period, as permitted by applicable law. If an investigative consumer report is requested, you have the right to receive a complete and accurate disclosure of the nature and scope of the investigation and a written summary of your rights under the FCRA.

If information from a consumer report is used in whole or in part to make an adverse employment decision, you will be provided with a copy of the report and a written description of your rights under the law.

Additionally, information you provide regarding current and/or previous employers may be used, and those employers may be contacted for the purpose of investigating your safety performance history, as required by 49 CFR 391.23(d) & (e). You have the right to: Review information provided by previous employers; Have errors in the information corrected by previous employers and for those employers to re-send the corrected information to the prospective employer; Have a rebuttal statement attached to the alleged erroneous information if a dispute over accuracy cannot be resolved.

AUTHORIZATION

I have carefully read and understood this Disclosure and Authorization Form. By signing below, I authorize Ballard Inc. and/or its designated agent to obtain and furnish consumer reports and/or investigative consumer reports, including but not limited to employment history, education, character, criminal record, credit standing, motor vehicle record, and other relevant background information.

I also authorize any law enforcement agency, institution (including learning institutions), information service bureau, credit bureau, record/data repository, court, motor vehicle record agency, employer, military entity, or other individual or source contacted by Ballard Inc. and/or its agent to provide the requested information for employment purposes.

I further authorize previous employers, schools, healthcare providers, and other persons or entities to release information in connection with my application and employment. I hereby release Ballard Inc., its agents, employees, and all individuals and entities providing information from any liability arising from the request for or release of such information.

I understand that any false or misleading information provided in my application or interview(s) may result in immediate termination of employment. I also acknowledge that I must comply with all the rules and regulations of the company.

I understand and agree that a facsimile (FAX) or photographic copy of this authorization will be as valid as the original.

Electronic Signature*

Please type your First and Last Name

*

I understand that checking this box constitutes a legal signature confirming that I acknowledge and agree to the above Terms of Acceptance

Date*

THE BELOW DISCLOSURE AND AUTHORIZATION 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 Ballard 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 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.

AUTHORIZATION

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

I authorize Ballard 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.

Electronic Signature*

Please type your First and Last Name

*

I understand that checking this box constitutes a legal signature confirming that I acknowledge and agree to the above Terms of Acceptance

Date*

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

Acknowledgement of Passport Requirement

I currently have a valid US passport*

Yes
No

If not, I hereby acknowledge that I am required to obtain a United States passport within 90 days of the start of my employment with Ballard Inc. Failure to obtain a passport within this 90 day period may be grounds for termination of my employment. I also acknowledge that if, at any time, I become ineligible to travel in or out of Canada due to issues of any kind my employment with Ballard Inc. may be terminated.

Electronic Signature*

Please type your First and Last Name

*