Test Form Continuation

Step 1 of 5

Full Name

this will be a hidden field that will connect the first form to this second form.
Social Security No*
Do you have at least one year of general maintenance and repair experience for Diesel Tractors?
- Yes
- No
Do you have at least one year of fabrication and hydraulic experience for Diesel Tractors?
- Yes
- No
How long since leaving last employment

Employment History
***Per D.O.T. Regulations, U.S. Drivers must complete the last ten (10) years of employment information. Canadian drivers must complete the last three (3) years of work history.
Select the number of past employers you've had in the past 10 years for U.S. Drivers, or the past 3 years for Canadian Drivers.
Company #1
Name*
Address
Street Address City State / Province / Region ZIP / Postal Code
Telephone
Position held
Start Date*
MM slash DD slash YYYY
End Date*
MM slash DD slash YYYY
Reason for leaving
Supervisor's name
May we contact employer prior to hiring?*
While employed here, were you subject to the Federal Motor Carrier Safety Regulations?*
Was the job designated as a safety-sensitive function in any Department of Transportation-regulated mode subject to alcohol and controlled substances testing as required by 49 CFR, part 40?*
Company #2
Name*
Address
Street Address City State / Province / Region ZIP / Postal Code
Telephone
Position held
Start Date*
MM slash DD slash YYYY
End Date*
MM slash DD slash YYYY
Reason for leaving
Supervisor's name
May we contact employer prior to hiring?*
While employed here, were you subject to the Federal Motor Carrier Safety Regulations?*
Was the job designated as a safety-sensitive function in any Department of Transportation-regulated mode subject to alcohol and controlled substances testing as required by 49 CFR, part 40?*
Company #3
Name*
Address
Street Address City State / Province / Region ZIP / Postal Code
Telephone
Position held
Start Date*
MM slash DD slash YYYY
End Date*
MM slash DD slash YYYY
Reason for leaving
Supervisor's name
May we contact employer prior to hiring?*
While employed here, were you subject to the Federal Motor Carrier Safety Regulations?*
Was the job designated as a safety-sensitive function in any Department of Transportation-regulated mode subject to alcohol and controlled substances testing as required by 49 CFR, part 40?*
Company #4
Name*
Address
Street Address City State / Province / Region ZIP / Postal Code
Telephone
Position held
Start Date*
MM slash DD slash YYYY
End Date*
MM slash DD slash YYYY
Reason for leaving
Supervisor's name
May we contact employer prior to hiring?*
While employed here, were you subject to the Federal Motor Carrier Safety Regulations?*
Was the job designated as a safety-sensitive function in any Department of Transportation-regulated mode subject to alcohol and controlled substances testing as required by 49 CFR, part 40?*
Company #5
Name*
Address
Street Address City State / Province / Region ZIP / Postal Code
Telephone
Position held
Start Date*
MM slash DD slash YYYY
End Date*
MM slash DD slash YYYY
Reason for leaving
Supervisor's name
May we contact employer prior to hiring?*
While employed here, were you subject to the Federal Motor Carrier Safety Regulations?*
Was the job designated as a safety-sensitive function in any Department of Transportation-regulated mode subject to alcohol and controlled substances testing as required by 49 CFR, part 40?*
Company #6
Name*
Address
Street Address City State / Province / Region ZIP / Postal Code
Telephone
Position held
Start Date*
MM slash DD slash YYYY
End Date*
MM slash DD slash YYYY
Reason for leaving
Supervisor's name
May we contact employer prior to hiring?*
While employed here, were you subject to the Federal Motor Carrier Safety Regulations?*
Was the job designated as a safety-sensitive function in any Department of Transportation-regulated mode subject to alcohol and controlled substances testing as required by 49 CFR, part 40?*
Company #7
Name*
Address
Street Address City State / Province / Region ZIP / Postal Code
Telephone
Position held
Start Date*
MM slash DD slash YYYY
End Date*
MM slash DD slash YYYY
Reason for leaving
Supervisor's name
May we contact employer prior to hiring?*
While employed here, were you subject to the Federal Motor Carrier Safety Regulations?*
Was the job designated as a safety-sensitive function in any Department of Transportation-regulated mode subject to alcohol and controlled substances testing as required by 49 CFR, part 40?*
Company #8
Name*
Address
Street Address City State / Province / Region ZIP / Postal Code
Telephone
Position held
Start Date*
MM slash DD slash YYYY
End Date*
MM slash DD slash YYYY
Reason for leaving
Supervisor's name
May we contact employer prior to hiring?*
While employed here, were you subject to the Federal Motor Carrier Safety Regulations?*
Was the job designated as a safety-sensitive function in any Department of Transportation-regulated mode subject to alcohol and controlled substances testing as required by 49 CFR, part 40?*
Company #9
Name*
Address
Street Address City State / Province / Region ZIP / Postal Code
Telephone
Position held
Start Date*
MM slash DD slash YYYY
End Date*
MM slash DD slash YYYY
Reason for leaving
Supervisor's name
May we contact employer prior to hiring?*
While employed here, were you subject to the Federal Motor Carrier Safety Regulations?*
Was the job designated as a safety-sensitive function in any Department of Transportation-regulated mode subject to alcohol and controlled substances testing as required by 49 CFR, part 40?*
Company #10
Name*
Address
Street Address City State / Province / Region ZIP / Postal Code
Telephone
Position held
Start Date*
MM slash DD slash YYYY
End Date*
MM slash DD slash YYYY
Reason for leaving
Supervisor's name
May we contact employer prior to hiring?*
While employed here, were you subject to the Federal Motor Carrier Safety Regulations?*
Was the job designated as a safety-sensitive function in any Department of Transportation-regulated mode subject to alcohol and controlled substances testing as required by 49 CFR, part 40?*

To be read and signed by applicant
This certifies that I prepared this application and that all information is true and complete. I authorize you to make investigations as to my employment, medical, financial, and other related matters necessary to make an employment decision. I hereby release anyone responding to these investigations of all liability related to the release of such information. I understand that false and misleading information in this application and interview(s) is cause for dismissal. If hired, I agree to abide by all lawful rules and regulations of the company.
Signature*
Date*
MM slash DD slash YYYY
Request for information from previous employer
I hereby authorize you to release the following information to ALTOM TRANSPORT, INC. For the purpose of investigation as required by section 391.23 and section 383.35 of the federal motor carrier safety regulations. You are released from any and all liability that may result from furnishing such information.
Applicant's Signature*
Date*
MM slash DD slash YYYY
Request for information concerning Alcohol and Controlled Substance testing
I hereby authorize your request for information concerning alcohol and controlled substance testing in compliance with section 382.405 of the federal motor carrier safety regulations.
Applicant's Signature*
Date*
MM slash DD slash YYYY

(1) Personnel Screening Questionnaire
Security: Have you ever been convicted of an offense against the law (other than a minor traffic violation), or are you now under charges for any offense against the law?
- Yes
- No
Please explain.
(2) Authorization & general release:
I hereby authorize Altom Transport, Inc. and all of their agents (Driver IQ) to request and receive any information and records concerning me, including but not limited to consumer credit, criminal record history, worker’s comp., driving, employment, military, civil and educational data and reports, from any individuals, corporations, parmerships, associations, institutions, schools, governmental agencies and departments, courts, law enforcement and licensing agencies, consumer reporting agencies and other entities, including my present and previous employers.

I further release and discharge Altom Transport, Inc., all of their agents (Driver IQ) and all of its subsidiaries and affiliates, and every employee or agent of any of them, and all individuals and personal, business, private or public entities of any kind, from any and all claims and liability arising out of any request(s) for, or receipt of, information or records pursuant to this authorization, or arising out of any compliance, or attempted compliance, with such request(s). I also authorize the procurement of an investigative consumer report and understand that it may contain information about my character, general reputation, personal characteristics, and mode of living, whichever are applicable. I understand that I have the right to make a written request within a reasonable period of time to Driver IQ, for a complete and accurate disclosure of additional information concerning the nature and scope of the investigation. I further understand that Driver IQ’s reporting of information pursuant to the Fair Credit Reporting Act is not intended to authorize or condone a prospective employer's request for and reliance upon information for purposes which are not legitimate under the Fair Credit Reporting Act or any federal or state employment laws. I acknowledge that I have voluntarily provided the above information for employment purposes, and I have carefully read and I understand this authorization.
Signed*
Date*
MM slash DD slash YYYY
IMPORTANT DISCLOSURE REGARDING BACKGROUND REPORTS FROM THE PSP Online Service
In connection with your application for the employment with Altom Transport, 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 day 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 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. You may 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 such 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 you PSP report. Since the PSP report does not report, or assign, or imply fault, it will include all Commercial Motor Vehicle (CMV) crashes 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 the Federal Motor Carrier Safety Regulations (FMCSR) violation 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 Altom Transport, 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 in 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 inspection, 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.
Signature*
Name
Date*
MM slash DD slash YYYY
NOTICE
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 from to obtain an Applicant’s consent. The language must be used in whole, exactly as provided. Further, the language on this form must exit as one stand-along 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 that definition of “employee” contained in 49 C.F.R 383.5.

Last Updated 12/22/2015
Altom Transport, Inc., 1646 Summer St, Hammond, IN 46320
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Test Form Continuation

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Step 1 of 5

Employment History

Company #1

Company #2

Company #3

Company #4

Company #5

Company #6

Company #7

Company #8

Company #9

Company #10

DRIVER QUALIFICATIONS

Drivers License Information

DRIVING EXPERIENCE

Tractor/Trailer

Accident Record For Past 7 Years

Traffic Convictions Last 7 Years

To be read and signed by applicant

Request for information from previous employer

Request for information concerning Alcohol and Controlled Substance testing

(1) Personnel Screening Questionnaire

(2) Authorization & general release:

IMPORTANT DISCLOSURE REGARDING BACKGROUND REPORTS FROM THE PSP Online Service

AUTHORIZATION

NOTICE