Southwind Freight and Global Logistics, L.P., d/b/aLevinge Freight Lines 17463 IH 45 North, Suite B Willis, Texas 77318
APPLICATION FOR EMPLOYMENT
APPLICANT: READ AND SIGN BEFORE SUBMITTING THIS APPLICATION
In compliance with Federal and State equal 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. It is agreed and understood that any misrepresentations of information given shall be considered an act of dishonesty. I understand that the information in this application will be used and that prior employers will be contacted for purposes of investigation as required by 391.23 of the Motor Carrier Safety Regulations. And I consent to references and former employers and educational institutions listed being contacted regarding this application and ascertain any and all information of concern to the applicants record whether same is of record or not applicant releases any persons name herein from all liability for any damages on account of his furnishing such information The applicant agrees to furnish such additional information and complete such examinations as may be required to complete his employment file. It is agreed and understood that this applicant for employment in no way obligates the employer to employee this applicant. And it is agreed and understood that if hired the employee will be placed on a trial basis during which time the applicant may be discharged without recourse.
Applicants Name: First Last Middle
Home Phone Other Contact No
Have you ever worked for this company before Yes No
(If yes) Dates: From: To:
Have you ever worked for this company under another name Yes No
(If yes what name)
Address for Past Three Years
Address Street City State ZIP How Long
Address Street City State ZIP How Long
Address Street City State ZIP How Long
Date of Birth Social Security Number Drivers Licence Number State
Education: Select highest grade completed
High School: 1 2 3 4
College: 1 2 3 4
Trade Schools:
Last School Attended - Name: City:
Driving Experience. Years operating
Straight Trucks: Tractor/Trailer: Flatbed: Hazmat: Over Size Load: Other:
Have you ever been denied a license, permit or privilege to operate a motor vehicle? Yes No
Has any license, permits or privilege ever been suspended or revoked? Yes No
Have you ever refused or tested positive for drugs? Yes No
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 automatic bar to employment-all circumstances will be considered.
Have you ever been disqualified for violations of the Federal Motor Carrier Safety Regulations? Yes No
Please Explain:
List Licenses held in the past three years.
List social courses that will help you as a driver
Driving awards held and who awards were presented by
Driving Experience.
Employment History for Driving Positions:
Please provide the last 10 years of your employment history. We understand that there are 11 spots for employment. Only fill out the necessary slots.
Employer Name Contact Person
Address
Position Held Start Date End Date
Salary Reason for Leaving
Employer Name Contact Person
Address
Position Held Start Date End Date
Salary Reason for Leaving
Employer Name Contact Person
Address
Position Held Start Date End Date
Salary Reason for Leaving
Employer Name Contact Person
Address
Position Held Start Date End Date
Salary Reason for Leaving
Employer Name Contact Person
Address
Position Held Start Date End Date
Salary Reason for Leaving
Employer Name Contact Person
Address
Position Held Start Date End Date
Salary Reason for Leaving
Employer Name Contact Person
Address
Position Held Start Date End Date
Salary Reason for Leaving
Employer Name Contact Person
Address
Position Held Start Date End Date
Salary Reason for Leaving
Employer Name Contact Person
Address
Position Held Start Date End Date
Salary Reason for Leaving
Employer Name Contact Person
Address
Position Held Start Date End Date
Salary Reason for Leaving
Employer Name Contact Person
Address
Position Held Start Date End Date
Salary Reason for Leaving
ACCIDENT RECORD
List all accidents in which you were involved as a driver in the preceding five years.
TRAFFIC VIOLATIONS
List all violations of motor vehicle law or ordinances (other than violations involving only parking) of which you were convicted or forfeited bond or collateral during the three years preceding the date of this application.
Personal references: Please list two
1 Name Phone# Relationship Length of Time Know
2 Name Phone# Relationship Length of Time Know
Signature - can be signed with a mouse or touchscreen.
Date
Process Record
Remarks
Southwind Freight and Global Logistics, L.P., d/b/aLevinge Freight Lines Pre-Employment Consent Form
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 substance test. A urine sample will be collected and tested for controlled substances. I also understand that if I test positive for use of controlled substances, I am not medically qualified to operate a commercial motor vehicle.
The results of the drug test will be maintained by the Medical Review Officer for the company who will report whether the test results were negative or positive to the motor carrier. I also authorize the results of the test to be released to other parties up to a period of two years.
I hereby agree to submit to a drug screen urinalysis.
In connection with my application for employment (including contract for services) with you, I understand that a consumer report, which may contain public record information, is being requested for DAC services. This report may include the following types of information; names and dates of previous employers, reason for termination of employment, work experience, accidents, etc. If further understand that such report may contain public record information concerning my driving record, worker’s compensation claims, credit, bankruptcy proceedings, etc, from federal, state and other agencies which maintain such records as well as information from DAC concerning (1) previous driving record request made by others from such state agencies, (2) state provided driving record, (3) claims involving me in the files of insurance companies.
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 information in its files on me at the time of my request; the source of information; the recipients of any report on me, which DAC has previously furnished within the two years 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, which subscribe to DAC services.
I understand that I am under a 90-day probation period and my continued employment depends upon my work performance.
If being hired as a driver only, I agree that if I terminate my employment in less than 90 days I will be charged for any fees for physical, drug screen and DAC report.
I have received the Levinge Freight Lines Handbook and I understand that I am responsible for all the rules and regulations listed in that handbook and any supplements to such.
Applicant's Printed Name Applicant's Social Security Number
Date
Applicant's Signature - can be signed with a mouse or touchscreen.
Southwind Freight and Global Logistics, L.P., d/b/aLevinge Freight Lines 17463 IH 45 North, Suite B Willis, Texas 77318
General Release
I authorize Southwind Freight and Global Logistics, L.P., d/b/a Levinge Freight Lines or DAC Services to investigate my background, credit rating, any possible criminal record, and prior work history, and agree that misrepresentation or omission of facts is a legitimate cause for decertification. This is in application for driver certification not employment.
I also authorize the release of information to safety personnel at Southwind Freight and Global Logistics, L.P., d/b/a Levinge Freight Lines or DAC Services concerning my past drug and alcohol test results and any refusals to be tested including pre-employment drug tests as required by the Federal Motor Carrier Safety Regulations. Title 49, Sections CFR 382.413 and 382.405.
Furthermore, I submit that I have been expressly notified of my rights regarding the investigative information provided to Southwind Freight and Global Logistics, L.P., d/b/a Levinge Freight Lines or DAC Services as outlined in FMCSR 391.23 which includes: 1) the right to review information provided by previous employers; (2) the right to have errors in the information corrected by the previous employer and for that employer to re-send the corrected information to Southwind Freight and Global Logistics, L.P., d/b/a Levinge Freight Lines or DAC Services; and (3) the right to have a rebuttal statement attached to the alleged erroneous information if the previous employer and I cannot agree on the accuracy of the information.
I understand that in order to receive such investigative information, I must submit a written request to Southwind Freight and Global Logistics, L.P., d/b/a Levinge Freight Lines or DAC Services within 30 days after being employed or being notified of denial of contract in order to review it and also understand that outhwind Freight and Global Logistics, L.P., d/b/a Levinge Freight Lines or DAC Services has five (5) business days in which to respond to my request.
DO NOT SIGN UNTIL YOU HAVE READ THE ABOVE STATEMENTS.
I certify that I have read and fully understand and accept all terms of the foregoing statements.
Signature - can be signed with a mouse or touchscreen.
Date Printed Name
IMPORTANT DISCLOSURE REGARDING BACKGROUND REPORTS FROM THE PSP Online Service
In connection with your application for employment with , (Prospective Employer), its employees, agents or contractors may obtain one or more reports regarding your driving, and safety inspection h istory 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 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. 1 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. 1 understand and acknowledge that this release of information may assist
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. 1 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.
Date :
Signature - can be signed with a mouse or touchscreen.
Printed Name Your Email
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.
LAST UPDATED 12/22/2015
