Has your permit, CDL or privilege to operate a motor vehicle ever been denied, suspended or revoked?
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.
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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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.
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.
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 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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Regarding background reports from the PSP Online Service
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 of application
LAST UPDATED 12/22/2015