Driver Employment Application arrow&amp;v Do you have legal right to work in the United States? Yes No Previous Three Years Residency State arrow&amp;v State arrow&amp;v State arrow&amp;v State arrow&amp;v State arrow&amp;v License Information No person who operates a commercial motor vehicle shall at any time have more than one driver's license (49 CFR 383.21). I certify that I do not have more than one motor vehicle license, the information for which is listed below. Include all licenses held for the past 3 years. State arrow&amp;v PREVIOUSLY HELD LICENSES State arrow&amp;v State arrow&amp;v Driving Experience Class of Equiptment Type of Equipment (Van, Tank, Flat, Etc.) Approx. No. of Miles (Total) Accident Record For Past 3 Years Or More Attach additional sheet if space is needed. Check this box if none None Dates ( List most recent first) Nature of Accident (Head-On, Rear-End, Upset, Etc.) No. of Injuries Chemical Spill Yes No Yes No Yes No Traffic Convictions and Forfeitures For The Past 3 Years (Other than Parking Violations) State of Violation Penalty (forfeited bond, collateral and/or points) State arrow&amp;v State arrow&amp;v State arrow&amp;v State arrow&amp;v A. Have you ever been denied a license, permit or privilege to operate a motor vehicle? If yes, please explain Yes No B. Has any license, permit or privilege ever been suspended or revoked? If yes, please explain Yes No The Federal Motor Carrier Safety Regulations (49 CFR 391.21) require that all applicants wishing to drive a commercial vehicle list all employment history for the last three (3) years. In addition, if you have driven a commercial vehicles previously, you must provide employment history for an additional seven (7) years (for a total of ten (10) years. Any gaps in employment excess of one (1) month must be explained. Start with the last or current position, including any military experience, and work backwards (attach separate sheets if necessary). You are required to list the complete mailing address, including street number, city, state, zip; and complete all other information. First (Most Recent) Employer While employed here, were you subject to the Federal Motor Carrier Safety Regulations? Yes No Was the job designated as a safety-sensitive function in any Department of Transportation-regulated mode subject to alcohol and controlled substances testing as required by 49 CFR, part 40? Yes No Second (Most Recent) Employer While employed here, were you subject to the Federal Motor Carrier Safety Regulations? Yes No Was the job designated as a safety-sensitive function in any Department of Transportation-regulated mode subject to alcohol and controlled substances testing as required by 49 CFR, part 40? Yes No Third (Most Recent) Employer While employed here, were you subject to the Federal Motor Carrier Safety Regulations? Yes No Was the job designated as a safety-sensitive function in any Department of Transportation-regulated mode subject to alcohol and controlled substances testing as required by 49 CFR, part 40? Yes No 31111 Old Wixom Rd. Wixom, MI 48393 Phone: 810-225-4415 Fax: 810-626-7400 Driver Signature Clear Please explain any gaps in employment history below: Education School Years Completed Graduate? Y N Y N Y N Other Qualifications TO BE READ AND SIGNED BY THE APPLICANT I authorize you to make investigations (including contacting current and prior employers) into my personal, employment, financial, medical history, and other related matters as may be necessary in arriving at an employment decision. I hereby release employers, schools, health care providers, and other persons from all liability in responding to inquiries and releasing information in connection with my application. In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I also understand that I am required to abide by all rules and regulations of the company. I understand that the information I provide regarding my current and/or prior employers may be used, and those employer(s) will be contacted for the purpose of investigating my safety performance history as required by 49 CFR 391.23. I understand that I will have the right to Review information provided by current/previous employers; Have errors in the information corrected by previous employers, and for those previous employers to resend corrected information to the prospective employer; and Have a rebuttal statement attached to the alleged erroneous information, If the previous employer(s) and I cannot agree on the accuracy of the information. This certifies that I completed this application, and that all entries on it and information in it are true and complete to the best of my knowledge. Note: A motor carrier may require an applicant to provide more information that that required by the Federal Motor Carrier Safety Regulations. Clear DMV Driving record authorization and Release for risk management purposes I, , give Matrix Transportation permission and authority to obtain driving record (transcript). The release of information from the Department of Motor Vehicles (DMV) is governed by VA. Code 46.3-208 through 214. This stipulates that all DMV records are privileged and are not available to the general public. DMV may only release driver, vehicle, and personal information from their records under the conditions specified in the statutes mentioned above. Matrix Transportation is using this information in their hiring process of employees using Matrix Transportation Vehicles. State arrow&amp;v signature Clear 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 MATRIX TRANSPORTATION("Prospective Employer"), Prospective Employer, its employees, agents or contractors may obtain one or more reports regarding you 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 not to 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 in 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 MATRIX TRANSPORTATION(“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 Clear 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. Submit Jump to Top Telephone: (888) 896-2405 Fax: (810) 229-6054 31111 Old Wixom Rd, Wixom, MI 48393, USA ©2022 Matrix Transportation proudly created by VNTG Point