Driver Application

Reliant Field Services, Inc.
432 Enterprise Drive - Victoria, TX 77905
361-582-4605 Fax 361-578-3622
TO BE READ AND SIGNED BY APPLICANT

I authorize you to make such investigations and inquiries of my personal, employment, financial or medical history and other related matters as may be necessary in arriving at an employment decision. (Generally, inquiries regarding medical history will be made only if and after a conditional offer of employment has been extended.) I hereby release employers, schools, health care providers and other persons from all liability in responding to inquiries and releasing information in connection with my application.

In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the Company.

"I understand that information I provide regarding current and/or previous employers may be used, and those employer(s) will be contacted, for the purpose of investigating my safety performance history as required by 49 CFR 391.23(d) and (e). I understand that I have the right to:

  • Review information provided by current/previous employers;
  • Have errors in the information corrected by previous employers and for those previous employers to re-send the corrected information to the prospective employer; and
  • Have a rebuttal statement attached to the alleged erroneous information, if the previous employer(s) and I cannot agree on the accuracy of the information."
Signature:
Date:
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Personal Information
Last Name:
First Name:
Middle Name:
Social Security Number:
Email Address:
Phone Number:
Date of Birth:
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Date of Hire:
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Current Address
Address:
City:
State:
Zip Code:
Number of Years:
Past 3 Year Residency
Address:
City:
State:
Zip Code:
Number of Years:
Address:
City:
State:
Zip Code:
Number of Years:
Employment History

All applicants wishing to drive in interstate commerce must provide the following information on all employers during the preceding three years. You must give the same information for all employers for whom you have driven a commercial vehicle seven years prior to the initial three years (total of ten year employment record).

You are required to list the complete mailing address: street number and name, city, state and zip code.

Current or Last Employer


Name:
Phone Number:
Address:
City:
State:
Zip Code:
Position Held:
From: (month/year)
To: (month/year)
Reason for Leaving:
Were you subject to the Federal Motor Carrier Safety Regulations** while employed?   
Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40?   
*ACCOUNT FOR PERIOD BETWEEN JOBS- Include dates (month/year) and reason:   

Second Last Employer


Name:
Phone Number:
Address:
City:
State:
Zip Code:
Position Held:
From: (month/year)
To: (month/year)
Reason for Leaving:
Were you subject to the Federal Motor Carrier Safety Regulations** while employed?   
Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40?   
*ACCOUNT FOR PERIOD BETWEEN JOBS- Include dates (month/year) and reason:   

Third Last Employer


Name:
Phone Number:
Address:
City:
State:
Zip Code:
Position Held:
From: (month/year)
To: (month/year)
Reason for Leaving:
Were you subject to the Federal Motor Carrier Safety Regulations** while employed?   
Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40?   
*ACCOUNT FOR PERIOD BETWEEN JOBS- Include dates (month/year) and reason:   

*Any gaps in employment and/or unemployment must be explained.

**The Federal Motor Carrier Safety Regulations 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.

Driving Experience
Do you have any driving experience in the last three years?   
Accident History
Have you had any accidents in the last three years?   
Traffic Convictions and Forfeitures
Have you had a traffic conviction and/or forfeiture in the last three years?   
License Information
Section 383.21 FMCSR states "No person who operates a commercial motor vehicle shall at any time have more than one driver's license". I certify that I do not have more than one motor vehicle license, the information for which is listed below.
State:
License Number:
Expiration Date:
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A. Have you ever been denied a license, permit, or privilege to operate a motor vehicle?   
B. Has any license, permit, or privilege ever been suspended or revoked?   
APPLICANT CERTIFICATION

This certifies that this application was completed by me, and that all entries on it and information in it are true and complete to the best of my knowledge.

Signature:
Date:
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BACKGROUND CHECK DISCLOSURE AND RELEASE AUTHORIZATION FORM FOR EMPLOYMENT PURPOSES
Background Screening Disclosure

Reliant Field Services (the "Company") may request a comprehensive review of your background information from a consumer reporting agency in connection with your employment application and for employment purposes, including promotion, reassignment, or retention as an employee. Your background information may be obtained in the form of consumer reports and/or investigative consumer reports. These reports may be obtained at any time after receipt of your authorization and, if you are hired by the Company, throughout your employment. Corra, 201 Continental Boulevard, Suite 107, El Segundo, CA 90245, 1-310-524-9800, and its designated agents and representatives or another consumer reporting agency will prepare or assemble the reports. The scope of the consumer report/investigative consumer report may include, but is not limited to, the following areas: consumer credit, names and dates of previous/current employment, worker's compensation claims, criminal history records (from local, state, federal, international and other law enforcement agencies' records), sexual offender's lists, wants and warrants records, motor vehicle records, military records, educational verification, license verification, civil cases, OIG/G5A, OFAC/patriot act, any sanction lists, finger printing and drug testing. These reports may include information as to your general reputation, character, personal characteristics, mode of living, work habits, job performance and experience along with reasons for termination of past employment from previous employers. You may request more information about the nature and scope of any investigative consumer reports by contacting the Company. A summary of your rights under the Fair Credit Reporting Act is also being provided to you.

Authorization and Release

I, , authorize the complete release of these records or data pertaining to me which an individual, company, firm, corporation, institution, school or university, law enforcement or public agency may have. I authorize the full release of the information described above, without any reservation, throughout any duration of my employment at the Company. I certify that all information provided below is true and accurate to the best of my knowledge. This authorization and consent shall be valid in original, facsimile ("fax"), or copy form. I understand that Corra's privacy practices can be found at http://www.corragroup.com/privacy-policy.html.

Signature:
Date:
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The following information is required by law enforcement agencies and other entities for identification purposes when checking records. It is confidential and will not be used for any other purpose.

Full Name (First Middle Last):
Maiden/AKA/Previous Name(s):
Social Security Number (SSN):
Date of Birth (This will not affect hiring decision):
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Driver's License Number:
State of Issue:
Current Address:
City:
State:
Zip Code:
Phone Number:

Corra Group Background Checks • 201 Continental Blvd, Ste 107, El Segundo, CA 90245-4598
TEL (310) 524-9800 • FAX (310) 774-3970 • www.corragroup.com

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 Reliant Field Services ("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, 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 Reliant Field Services ("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, 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.

Signature:
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.

Last Updated 12/22/2015