Applicant information
Must list all addresses for previous 3 years.
Emergency contact person
Driver license information
Drivers experience
Has your permit, CDL or privilege to operate a motor vehicle ever been denied, suspended or revoked?
Tickets/Accidents/Etc.
Please list all motor vehicle collisions in which you were involved (both commercial or private vehicle) during the past 3 years prior to the application date.
Traffic Convictions & Forfeitures for past 3 years.
Employment Record
Have you been a driver for this company before?
Note: Please list all motor vehicle collisions in which you were involved (both commercial or private vehicle) during the past 3 years prior to the application date.
Have you, the applicant, tested positive, or refused to test, on any pre-employment drug or alcohol test administered by an employer to which you applied for, but did not obtain, safety+sensitive transportation work covered by DOT agency drug and alcohol testing rules during the past two years?
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Authorization for release of information for insurance underwriting
Driver Record Consent Form
I hereby authorize Embark Safety LLC and its designated agents and representatives to conduct a comprehensive review of my driver record background through a consumer report and/or an investigative consumer report to be generated for insurance purposes. Upon Request, Embark Safety LLC will supply a copy of the completed consumer report along with a copy of an individual’s rights under the Fair Credit Reporting Act.
Authorization and Release
I , authorize the complete release of these records or data pertaining to me which an individual, company, firm, corporation, or public agency may have. I authorize the full release of the information described above, without any reservation, to my insurance company . I hereby release Embark Safety LLC, LLC, and its agents, officials, representatives, or assigned agencies, including officers, employees, or related personnel both individually and collectively, from any and all liability for damages of whatever kind, which may at any time, result to me, my heirs, family or associates because of compliance with this authorization for release form. I certify that all information provided below and on my insurance application is correct to the best of my knowledge. This authorization and consent shall be valid in original, fax, or copy form. 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.
First name
Middle name
Last name
State
Date of birth
Social Security Number
Notice to California Applicants: Under section 1786.22 of California Civil Code, you have the right to request from Embark Safety LLC, upon proper identification, the nature and substance of all information in files pertaining to you, including the sources of information, and recipients of any reports on you, which Embark Safety LLC during normal business hours. You may also obtain a copy of this file upon submitting proper identification. Upon making a written request, you may receive a summary of your report.
Notice to Maine Applicants: Under Chapter 210 Section 1314 of Maine revised Statutes, you have the right, upon request,to be informed within 5 business days of such a request to whether or not an investigative consumer report was requested. If such report was obtained, you may contact the Consumer Reporting Agency and request a copy. Notice to massachusetts Applicants: Under Mass. Ann. Laws chapter. 93 50, a Consumer Reporting Agency may furnish a report if intended to be utilized for employment purposes.
Notice to New York Applicants: Under Article 25 Section 380-c (b) (2) of the New York General Business Law, you have the right, upon written request, to be informed of whether or not an investigative consumer report was requested. Under Article 25 Section 380-g of the New York General Business Law, should a consumer report received by an employer contain criminal conviction information, the employer must provide to the applicant or employee who is the subject of the report, a printed or electronic copy of Article 23-A of the New York Correction Law, which governs the employment of persons previously convicted of one or more criminal offenses.
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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 SKY VISION INC. (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 SKY VISION 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 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
Date of application
Name
Surname
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.
Notice: The prospective employment concept referenced in this form contemplates the definition of “employee” contained at 49 C.F.R. 383.5.
LAST UPDATED 12/22/2015
