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First Name
MI
Last Name
DOB
Telephone Number
Cell Phone
Email
RECENT ADDRESS(ES)
Address
City
State
Zip
Address
City
State
Zip
Address
City
State
Zip
APPLYING TO BLISS FREIGHT
How were you referred to Bliss Freight
Have you ever driven with Bliss Freight in the past? Provide dates & reason for leaving:
Can you submit evidence that you are at least 23 years of age?
Yes
No
EMPLOYMENT HISTORY
Employer
Address
City
State
Zip
Job Title
Dates Employed
Phone Number
Starting Pay Rate
Ending Pay Rate
Employer
Address
City
State
Zip
Job Title
Dates Employed
Phone Number
Starting Pay Rate
Ending Pay Rate
Employer
Address
City
State
Zip
Job Title
Dates Employed
Phone Number
Starting Pay Rate
Ending Pay Rate
EDUCATION & MILITARY STATUS
Highest Grade/GED
College Degree
Have you served in the U.S Armed Forces?
Branch
Reserve Status
Rank at Discharge
Additional Information & Education
Add any additional information you regard as pertinent to the position for which you have applied:
References
First/Last Name
Phone Number
Relationship
First/Last Name
Phone Number
Relationship
Criminal Background
This information will be verified with all previous employers for the prior three years, in accordance with Department of Transportation regulations
Have you ever tested positive for controlled substances?
Yes
No
Have you ever tested at .02 or higher alcohol concentration?
Yes
No
Have you ever refused to submit to a controlled substance or alcohol test?
Yes
No
Have you ever tested positive or refused a pre-employment drug or alcohol test?
Yes
No
If you have answered YES to any of the above questions, please provide documentation from the Substance Abuse Professional of your release.
HAVE YOU EVER BEEN CONVICTED OF, FORFEITED BOND OR COLLABORATED UPON, ANY OF THE FOLLOWING CHARGES:
A felony? (If YES, explain in detail, giving dates, etc.)
A misdemeanor? (If YES, explain in detail, giving dates, etc.)
A felony, the commission of which involved the use of a motor vehicle?
Yes
No
A crime involving the manufacturing, knowing transportation, possession, sale or habitual use of amphetamines, a narcotic drug, a formulation of an amphetamine, or a derivative of a narcotic drug?
Yes
No
Operating a motor vehicle under the influence of drugs or alcohol?
Yes
No
Leaving the scene of an accident resulting in personal injury or death?
Yes
No
If YES to any of the above, explain in detail:
TO BE READ AND SIGNED BY THE APPLICANT:
I authorize Bliss Freight (including DAC, PSP and Bureau of Motor Vehicles) to make such investigations and inquiries of my personal, work, financial driving and medical history and other related matters as may be necessary in arriving at a leading decision. I hereby authorize employers, schools or persons to release all records of employment including assessments of my job performance, ability, fitness, driving history alcohol testing and controlled substance history to each and every company or authorized agent which may request such information in connection with my application with said company. I hereby release employers, schools or persons from all liability in responding to inquiries in connection with my application. By signing below, I acknowledge that I can read, speak and understand the English language sufficiently as required by 49 CFR 391.11(b)(2). Further, I acknowledge that if English is my secondary language and I don’t understand have difficulty understanding any information contained in this application or the remaining application materials or manuals, I will contact Bliss Freight and request a translation or interpreter. Further, by signing below, I acknowledge that I have received the disclosure titled “Important Disclosure Regarding Background Reports from the PSP Online Service.” I understand that this disclosure and authorization is not generated or created by Bliss Freight and any references to employment relationship including, but not limited to the terms prospective employer, employee, and employment are not to be construed as creating an employer/ employee relationship between an Operator/Driver and Bliss Freight. I also understand that Bliss Freight does not employ drivers, but contracts with Owner-Operators and Third-Party Fleet Drivers who provide driving services to Bliss Freight pursuant to an Equipment Lease and Service Agreement. In the event of qualification, I understand that false or misleading information given in this application or interview(s) may result in disqualification and or cancellation of my lease agreement. I further understand that I am required to abide by all rules and regulations of the Company and Department of Transportation as permitted by law. In accordance with DOT regulations 391.23 the driver has the right to review information provided by previous employers; the right to have errors in the information corrected by the previous employer and for that previous employer to re-send the corrected information; the right to have a rebuttal statement attached to the alleged erroneous information. This must be requested in writing within 30 days of contracting or denial of contracting. This certifies the application above, was completed by myself, and that all entries within are true and complete to the best of my knowledge. I further recognize that any fraudulent or intentionally false entries or statements on any application, certificate, report, or record is strictly prohibited by the Federal Regulations. (49 CFR 390.35). This application for an Independent Contractor Position: with Bliss Freight is pending the results of my Motor Vehicle Report, results of any Controlled Substance/Alcohol testing and inquiries to previous employers
Date
Contractor/Applicants Signature
IMPORTANT DISCLOSURE – REGARDING BACKGROUND REPORTS FROM THE PSP (ONLINE SERVICE)
In connection with your application for employment with Bliss Freight (“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 Bliss Freight (“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.
Date
Contractor/Applicants Signature
Submit
TRUCKING 2019. All RIGHTS RESERVED.
DESIGNED AND DEVELOPED BY THINKING GEAR.
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