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I hereby certify that all information on this form is correct and complete to the best of my knowledge. I hereby authorize BTC/MDS/TTI, to do a complete background investigation in accordance with state and federal laws. I authorize release of any information, including all information related to my alcohol and controlled substances testing and training records required by the Federal Highway Administration (FHWA) 49 CFR parts 391 and 382, by any past or current employers. I hereby release all such persons from any liability or damages. I consent to the procurement and use of any consumer reports, including reports from DAC Services, Inc., deemed necessary by BTC/MDS/TTI or its subsidiaries in their consideration of my employment.

I understand that I have tht right to review information provided by previous employers, have errors corrected by previous employer and resubmitted to BTC/MDS/TTI and/or have a rebuttal statement attached to erroneous information if my previous employer and I cannot agree on the accuracy of the information. I understand that I must request past employer information obtained by BTC/MDS/TTI in writing within 30-days of my application.

I indicate that I understand the above information and agree with all terms by entering my initials: *

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First Name * Middle Initial Last Name *

Date of Birth (mm dd yy): *         Social Security Number *      Phone *

Address *
 
City * 
State * 
Zip *
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Email * 
License# * 
State *
      Endorsements
Tickets in last 3 years? *
Accidents in last 3 years? *

Are you 23 years or older? *

Have you worked for this company before? *   If yes, when?

Are you a US Citizen? *   If not, do you have a legal right to live and work in the U.S.? *

Have you ever tested positive or refused to test on any pre-employment Drug or Alcahol test administered by an employer to which you applied for, but did not obtain employment during the past three years? *

Last / Current Employer

Employer Name * Employer Phone # *
Are you presently employed? * May we call your current employer? *
Employer Address
Position Held From * To *
Why do you want to change employers?

Were you subject to the FMCSR's? *   Was Job Designated as a Safety Sensitive function in any DOT regulated mode subject to drug and alcohol testing as required by 49 CFR part 40? *

Second Last Employer

Employer Name Employer Phone #
Employer Address
Position Held From To
Why did you quit?

Were you subject to the FMCSR's?   Was Job Designated as a Safety Sensitive function in any DOT regulated mode subject to drug and alcohol testing as required by 49 CFR part 40?

 

Third Last Employer

Employer Name Employer Phone #
Employer Address
Position Held From To
Why did you quit?

Were you subject to the FMCSR's?   Was Job Designated as a Safety Sensitive function in any DOT regulated mode subject to drug and alcohol testing as required by 49 CFR part 40?