Employment Application Step 1 of 4 25% Driver’s ApplicationWarehouse ApplicationPosition applied for Driver Warehouse Employee IMPORTANT DISCLOSURE REGARDING BACKGROUND REPORTS FROM THE PSP Online Service In connection with your application for employment with GREEN TRANSFER & STORAGE CO (“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 GREEN TRANSFER & STORAGE CO (“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.Signature(Required) General InformationName First Last DOB MM slash DD slash YYYY SSN (last 4 digits)Email PhoneCurrent Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Are you eligible to work in the US? Yes No In case of emergency notify: First Last Emergency Contact PhoneEmergency Contact Address Street Address Address Line 2 City State ZIP Have you worked for this company before? Yes No Date from MM slash DD slash YYYY Date to MM slash DD slash YYYY PositionReason for leavingAre you now employed? Yes No How long since leaving your last employment?Who referred you?Pay rate expected (per hour) Physical HistoryAre you able to preform the duties described belowAbility to push, pull, crank, turn, lift and carry 50 pounds. Ability to use steps to climb into and out of truck cab. Continuously bend, stoop, kneel, squat. Ability to throw chain and strap over cargo on trailer and secure using a winch bar. Ability to place dunnage on trailer for loading and remove dunnage from trailer once unloaded. Yes No List any limitations that prevent you from performing the duties listed. Specify any medical waivers.Employment HistoryEnter the past 7 years of employment history.Employee Row ID Employer From To Actions Edit Delete There are no Employees. Add Employer Maximum number of employees reached. Employee Row ID Employer From To Actions Edit Delete There are no Employees. Add Employer Maximum number of employees reached. Accident RecordEnter all accident records for the past 3 years.Accident History Row ID Nature of Accident Date Injury Fatalities Actions Edit Delete There are no Accidents. Add Accident Maximum number of accidents reached. Traffic Convictions & ForfeituresEnter all traffic convictions & forfeitures for the past 3 years.Traffic Violations Row ID Location Date Charge Penalty Actions Edit Delete There are no Traffic Violations. Add Traffic Violation Maximum number of traffic violations reached. Experience & QualificationsValid license currently heldStateLicense NumberTypeExpiration Date MM slash DD slash YYYY Driving ExperienceType of equipment & approximate miles/hours driven.Class Straight Truck Tractor/Trailer Doubles Type Van Tank Flat Other MilesFromToHave you even been denied a license, permit or priviledge to operate a motor vehicle? Yes No Has any lincese, permit or priviledge ever been suspended or revoked? Yes No Explain detailsIn the past 5 years, have you tested positive, or refused to test, on a pre-employment drug or alcohol test administered by an employer where you applied for a safety sensitive position and were not hired? Yes No List states licensed in for past 5 yearsConsent and SignatureConsent I agree to the privacy policy.Signature(Required)