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DRIVER PRE-QUALIFICATION CERTIFICATION
I. DRIVER PRE-QUALIFICATION CERTIFICATION I hereby certify that all of the facts and information listed on this application are true and complete. I understand that any false, incomplete or misleading information given by me on this application is sufficient cause for rejection of this application. I also understand and agree that any such false, incomplete, or misleading information discovered on this application at any time after I am employed or become an independent contractor for leased to Fidelis may result in termination of my lease. I hereby authorize the Company to investigate all statements contained in this application and to interview the references and previous employers/lessees listed in this application, and to obtain a report from a consumer-reporting agency to be used for screening purposes in accordance with the Fair Credit Reporting Act. I authorize the references and previous employers/lessees listed to give the Company all facts, opinions and evaluations concerning my previous work and any other information they may have, personal or otherwise, and to release all such parties from any liability which may allegedly arise from furnishing such information to the Company, including, but not limited to, any liability for defamation or invasion of privacy. If I am offered a contract for lease, I understand that such an offer will be conditioned upon satisfactory results of a background investigation and/or Company medical examination or inquiry, including a drug screen test. I further understand that my contract lease can be terminated as detailed in the owner/operator contract. I understand that no supervisor or other representative of the Company other than the President of the Company has any authority to enter into any agreement for any specified period of time, or to make any agreement contrary to the foregoing. I understand that the President of the Company can enter into an agreement for a specified period of time only where such agreement is in writing. If my application is accepted, I understand that it is my responsibility to keep accurate and complete records of my trips and expenses as detailed in the owner/operator contract. I further understand and voluntarily agree to submit to a urinalysis or other drug screen test and that my failure to take such test(s), or unsatisfactory test results, will disqualify me from consideration for contract/lease or will result in the immediate termination of my contract/lease. I understand that references to “employment” in this agreement shall be understood to also apply to lease applications for “independent contractors” and shall not be construed as defining any prospective independent contractor relationship as being one of employment between Fidelis Freight and the applicant. II. CONSUMER DISCLOSURE AND AUTHORIZATION FORM Disclosure Regarding Background Investigation Fidelis Freight (the “Company”) may request, for lawful employment purposes, background information about you from a consumer reporting agency in connection with your employment or application for employment (including independent contractor assignments, as applicable). This background information may be obtained in the form of consumer reports and/or investigative consumer reports (commonly known as “background reports”). These background reports may be obtained at any time after receipt of your authorization and, if you are hired or engaged by the Company, throughout your employment or your contract period. HireRight, Inc., or another consumer reporting agency, will prepare or assemble the background reports for the Company. HireRight, Inc. is located and can be contacted by mail at 5151 California, Irvine, CA 92617, and HireRight can be contacted by phone at (800) 400-2761. Information about HireRight’s privacy practices is available at www.hireright.com/Privacy-Policy.aspx. The background report may contain information concerning your character, general reputation, personal characteristics, mode of living, and credit standing. The types of information that may be obtained include, but are not limited to, social security number verifications; address history; credit reports and history; criminal records and history; public court records; driving records; accident history; worker’s compensation claims; bankruptcy filings; educational history verifications (e.g., dates of attendance, degrees obtained); employment history verifications (e.g., dates of employment, salary information, reasons for termination, etc.); personal and professional references checks; professional licensing and certification checks; drug/alcohol testing results; and drug/alcohol history in violation of law and/or company policy; and other information bearing on your character, general reputation, personal characteristics, mode of living and credit standing. This information may be obtained from private and public record sources, including, as appropriate; government agencies and courthouses; educational institutions; former employers; personal interviews with sources such as neighbors, friends and associates; and other information sources. If the Company should obtain information bearing on your credit worthiness, credit standing or credit capacity for reasons other than as required by law, then the Company will use such credit information to evaluate whether you would present an unacceptable risk of theft or other dishonest behavior in the job for which you are being evaluated. You may request more information about the nature and scope of any investigative consumer reports by contacting the Company. A summary of your rights under the Fair Credit Reporting Act is also being provided to you. III. AUTHORIZATION OF BACKGROUND INVESTIGATION l have carefully read and understand this Disclosure and Authorization form and the attached summary of rights under the Fair Credit Reporting Act. By my signature below, I consent to preparation of background reports by a consumer reporting agency such as HireRight, Inc., and to the release of such background reports to the Company and its designated representatives and agents, for the purpose of assisting the Company in making a determination as to my eligibility for employment (including independent contractor assignments, as applicable), promotion, retention or for other lawful employment purposes. I understand that if the Company hires me or contracts for my services, my consent will apply, and the Company may obtain background reports, throughout my employment or contract period. I understand that information contained in my employment or contractor application, or otherwise disclosed by me before or during my employment or contract assignment, if any, may be used for the purpose of obtaining and evaluating background reports on me. I also understand that nothing herein shall be construed as an offer of employment or contract for services. I hereby authorize law enforcement agencies, learning institutions (including public and private schools and universities), information service bureaus, credit bureaus, record/data repositories, courts (federal, state and local), motor vehicle records agencies, my past or present employers, the military, and other individuals and sources to furnish any and all information on me that is requested by the consumer reporting agency. IV. IMPORTANT NOTICE REGARDING BACKGROUND REPORTS FROM THE PSP ONLINE SERVICE 1. In connection with your application for employment with Fidelis Freight Transport Services LLC. (“Prospective Employer”), it 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. The Prospective Employer cannot obtain background reports from FMCSA unless you consent in writing. If you agree that the Prospective Employer may obtain such background reports, please read the following and sign below: 2. I authorize Fidelis 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 consenting to 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 or independent contractor. 3. I further understand that neither the Prospective Employer not 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 am challenging 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. 4. Please note: 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 FMCSA violations that have been adjudicated by a court of law will also appear, and remain, on a PSP report. I have read the above Notice Regarding Background Reports provided to me by Prospective Employer and I understand that if I sign this consent form, 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. V. THE FIDELIS FREIGHT: APPLICANT ACKNOWLEDGEMENT OF THE FAIR CREDIT REPORTING ACT A Summary of Your Rights Under the Fair Credit Reporting Act: The Federal Fair Credit Reporting Act (FCRA) is designed to promote accuracy, fairness, and privacy of information in the files of every “consumer reporting agency” (CRA). Most CRAs are credit bureaus that gather and sell information about you– such as if you pay your bills on time or have filed bankruptcy– to creditors, employers, landlords, and other businesses. You can find that the complete text of the FCRA, 15 U.S.C. 1681-1681u, at the Federal Trade Commission’s web site (http://www.ftc.gov). The FCRA gives you specific rights, as outlined below. You may have additional rights under the state law. You may contact a state or local consumer protection agency or a state attorney to learn these rights. You must be told if information in your file has been used against you. Anyone who uses information from a CRA to take action against you– such as denying an application for credit, insurance or employment– must tell you, and give you the name, address, and phone number of the CRA that provided the consumer report. You can find out what is in your file. At your request, a CRA must give you the information in your file, and a list of everyone who has requested it recently. There is no charge for the report if a person has taken action against you because of information supplied by the CRA if you request the report within 60 days of receiving notice of the action. You also are entitled to one free report every twelve months upon request if you certify that (1) you are unemployed and plan to seek employment within 60 days, (2) you are on welfare, or (3) your report is inaccurate due to fraud. Otherwise, a CRA may charge you up to eight dollars. You can dispute inaccurate information with the CRA. If you tell a CRA that your file contains inaccurate information, the CRA must investigate the items (usually within 30 days) by presenting to its information source all relevant evidence you submit, unless your dispute is frivolous. The source must review your evidence and report its findings to the CRA. The source also must advise national CRA’s– to which it has provided the data–of any error. The CRA must give you a written report of the investigation, and a copy of your report if the investigation results in any change. If the CRA’s investigation does not resolve the dispute, you may add a brief statement to your file. The CRA must normally include a summary of your statement in future reports. If an item is deleted or a dispute statement is filed, you may ask that anyone who has recently received your report be notified of the change. Inaccurate information must be corrected or deleted. A CRA must remove or correct inaccurate or unverified information from its files, usually within 30 days after you dispute it. However, the CRA is not required to remove accurate data from your file unless it is outdated (as described below) or cannot be verified. If your dispute results in any change to your report, the CRA cannot reinsert into your file a disputed item unless the information source verifies its accuracy and completeness. In addition, the CPA must give you a written notice telling you it has reinstated the item. The notice must include the name, address, and phone number of the information source: DISCLOSURE/AUTHORIZATION FORM By this document, Fidelis Freight discloses to you that a consumer report may be obtained for employment purposes as part of the pre-screening background check and at any time during your employment or affiliation. This shall authorize the procurement of a consumer report by National Employment Screening DBA Premium Background Checks or its associates or other sources as part of the pre-screening background investigation. If accepted, this authorization shall remain on file and shall serve as an ongoing authorization for National Employment Screening/Premium Background Checks or its associates or other sources to procure consumer reports at any time during my affiliation or employment period. I also authorize the procurement of an investigative consumer report and understand that it may contain information about my employment and educational background, criminal history, credit, mode of living, character and personal reputation. I understand that I have the right to obtain additional disclosure as to the nature and scope of the investigation upon written request within a reasonable period of time and to obtain a copy of the report upon request. This authorization, in original or copy form, shall be valid for this and any future reports or updates that may be requested. In connection with this request, I authorize all corporations, companies, former employers, supervisors, credit agencies, educational institutions, law enforcement/criminal justice agencies, city, state, county and federal courts, state motor vehicle bureaus and persons to release information they may have about me to the person or company with which this form has been filed if required, or their agent, National Employment Screening/Premium Background Checks or its affiliates. FAIR CREDIT REPORTING ACT - DISCLOSURE TO APPLICANTS Pursuant to the Fair Credit Reporting Act, 15 U.S.C. § 1681-1681u, Fidelis Freight, is providing this notice that Fidelis Freight may obtain a consumer report, (including, but not limited to, a credit report) concerning you for employment purposes and in conjunction with either your application for employment or, if employed, any decisions concerning your employment status with Fidelis Freight. My signature below also indicates that I have received a summary of rights in accordance with the Fair Credit Reporting Act. FAIR CREDIT REPORTING ACT - AUTHORIZATION TO OBTAIN CONSUMER REPORT I hereby authorize Fidelis Freight to at any time obtain a consumer report (including, but not limited to, a credit report) concerning me. It is my understanding that Fidelis Freight will use the consumer report for employment purposes and in conjunction with either my application for employment and/or decisions concerning my employment status with Fidelis Freight. This authorization remains effective until it is revoked in writing by me. I release and hold harmless all parties involved from any and all liability for damages arising from requesting, procuring, or furnishing the requested information except with respect to a violation of the Act. I authorize National Employment Screening DBA Premium Background Checks and its clients to receive any criminal history information or credit report pertaining to me in the files of any state or local criminal justice agency. VI. FIDELIS FREIGHT FMCSA PRE-EMPLOYMENT SCREENING PROGRAM (PSP) In connection with your application with Fidelis Freight, it may obtain one or more reports regarding your driving and safety inspection history from the Federal Motor Carrier Safety Administration (FMCSA). If Fidelis Freight Transport Services LLC uses any information it obtains from FMCSA in a decision to not obtain you as a driver or to make any other adverse decisions regarding you, Fidelis Freight 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, Fidelis Freight will notify you that the action has been taken and that the action was based in part or in whole on this report. Fidelis Freight cannot obtain background reports from the FMCSA unless you consent in writing. If you agree that Fidelis Freight may obtain such background reports, please read the following and sign below: I authorize Fidelis Freight to access the FMCSA Pre-Employment Screening Program system to seek information regarding my commercial driving safety record and information regarding my safety inspection history. I understand that I am consenting to 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 Fidelis Freight to make a determination regarding my suitability as a driver with their company. I further understand that neither Fidelis Freight 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.frmrsa.dot.gov. If I am challenging 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 have read the above Notice Regarding Background Reports provided to me by Fidelis Freight and I understand that if I sign this consent form, Fidelis Freight may obtain a report of my crash and inspection history. I hereby authorize Fidelis Freight and its employees, authorized agents, and/or affiliates to obtain the information authorized above. VII. FIDELIS FREIGHT: NOTICE TO APPLICANTS OF THE DRUG FREE WORKPLACE PROGRAM Fidelis Freight has established a Drug Free Workplace Program. Contractors/Lessees are prohibited from using illegal drugs (including the non-prescribed use of prescription medication) on or off the Fidelis Freight premises and are also prohibited from possessing or transporting alcohol or illegal drugs on the premises. Possession of paraphernalia used in connection with the use of any drug is evidence of violation of this rule. Drugs mean alcohol, including distilled spirits, wine, malt beverages and intoxicating liquors, amphetamines, cannabinoids, cocaine, phencyclidine (PCP), hallucinogens, methaqualone, opiates, barbiturates, benzodiazepines, synthetic narcotics, designer drugs or metabolite of any of these substances. Non-prescribed use of prescription medication is also prohibited. This company will require all applicants and existing lessees, under certain circumstances, to be tested for the presence of drugs or alcohol as part of this company’s policy prohibiting drug or alcohol use. Anyone violating the Drug Free Workplace Program by testing positive in a confirmed test for drugs or refusing to cooperate in the drug testing procedure, will be treated as a positive confirmed test for drugs. Upon conviction for violating any state or federal drug law, each applicant, contractor or lessee of this company is required to notify his or her immediate supervisor of such conviction within five business days thereof. This “notification of drug conviction” requirement applies whether the conviction resulted from conduct performed while in the course and scope of employment or off duty. Contractors and lessees are required to report any drug related criminal charge brought against them, whether the result of on-duty or off-duty conduct. Any violation of this rule will result in contract termination. CONTRACTOR/LESSEE AGREEMENT - PLEASE READ CAREFULLY I freely and voluntarily agree to submit to a urinalysis (drug screen) as part of my application process. I understand that either refusal to submit to the urinalysis screen or failure to qualify according to the minimum standards established by the company for this screen will disqualify me from further contract consideration. I further understand that upon commencement of contract/lease with the company, I may again be required to submit to a urinalysis screen. I understand that refusal to take a requested urinalysis screen or failure to meet the minimum standards set for the screen may result in immediate contract termination. In the event that my contract/lease commences prior to the company receiving the drug test results, I understand that my contract will be immediately terminated if the result comes back positive. I have read in full and understand the above statements and conditions of employment. VIII. RELEASE TO GIVE REFERENCE In order to provide Fidelis Freight Transport Services LLC with information and opinions that may be useful in its hiring decisions, I hereby authorize the persons, schools, current and past employers, organizations or entities disclosed in my resume, application, or during my interview to provide information regarding me. This authorization includes without limitation, information concerning my performance, drug and alcohol screenings, reputation and character, background and driver’s license information as required in Sections 391.23 and 391.25 of the Federal Motor Carrier Safety Regulations. I acknowledge that the information divulged may be negative or positive with respect to me, nevertheless, pursuant to this authorization, I unconditionally release such persons, schools, employers, organizations or entities from any and all legal liability for furnishing such information and in making such statements. A photocopy of this signed release shall have the same force and effect as the original release signed by me. IX. TEXT MESSAGES & ELECTRONIC COMMUNICATIONS Fidelis Freight may contact you with business-related announcements from time to time upon approval of Application and Lease. These announcements include, but are not limited to, changes in policies and information pertaining to your settlement. We will use your provided phone number to keep you updated on company news and special offers. We do not disclose personal contact information about our applicants with anyone outside of Fidelis Freight unless required to do so in order to process your application. I certify that I have read, understand and agree with the above and that the information I provided on and in connection with this form is true, accurate and complete. I agree that this application in original, faxed, photocopied or electronic (including electronically signed) form will be valid for any background reports that may be requested by or on behalf of Fidelis Freight Transport Services, LLC. to verify my driving record.
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