MENU EMPLOYMENT APP Personal Information LAST NAME FIRST NAME MIDDLE DATE OF APPLICATION CURRENT AND PREVIOUS 3 YEARS ADDRESS CITY STATE ZIP ADDRESS CITY STATE ZIP ADDRESS CITY STATE ZIP HOME TELEPHONE MOBILE EMAIL EMERGENCY CONTACT INFO HOME TELEPHONE MOBILE RELATIONSHIP DO YOU HAVE THE LEGAL RIGHT TO WORK IN THE UNITED STATES? SOCIAL SECURITY # DATE OF BIRTH (MM/DD/YY) DL# TYPE STATE EXPIRATION HAVE YOU EVER BEEN BONDED? NAME OF BONDING COMPANY HAVE YOU EVER BEEN CONVICTED OF A FELONY? IF YES, PLEASE EXPLAIN FULLY ON A SEPARATE SHEET OF PAPER. CONVICTION OF A CRIME IS NOT AN AUTOMATIC BAR TO EMPLOYMENT - ALL CIRCUMSTANCES WILL BE CONSIDERED. HOW DID YOU LEARN ABOUT OUR COMPANY? DO YOU HAVE A NON-COMPETE / NON-DISCLOSURE AGREEMENT IN PLACE WITH ANY FORMER EMPLOYER YesNo POSITION / SHIFT POSITION / SHIFT SOUGHT AVAILABLE START DATE ARE YOU ABLE TO PERFORM THE ESSENTIAL FUNCTIONS OF THE POSITION WITH OR WITHOUT ACCOMMODATIONS? IF NECESSARY FOR THE JOB I AM ABLE TO WORK WHICH SHIFTS? DayNightOvertimeAny DESIRED PAY RANGE ARE YOU CURRENTLY EMPLOYED? YesNo WHERE? HAVE YOU WORKED FOR THIS COMPANY BEFORE? IF SO, WHEN? EDUCATION LAST SCHOOL ATTENDED CITY/STATE HIGHEST LEVEL OF EDUCATION COMPLETED PLEASE LIST COURSES OR TRAINING, SPECIAL EQUIPMENT OR TECHNICAL MATERIALS YOU CAN WORK WITH, AREAS OF HIGHEST PROFICIENCY, SPECIAL SKILLS OR OTHER ITEMS THAT MAY CONTRIBUTE TO YOUR ABILITIES IN PERFORMING THE ABOVE MENTIONED POSITION. INCLUDE SAFE DRIVING AWARDS THAT YOU HOLD AND FROM WHOM. EXPERIENCE AND QUALIFICATIONS LIST ALL DRIVER LICENSES OR PERMITS HELD IN THE PAST 3 YEARS. LICENSE NO. TYPE STATE EXPIRATION LICENSE NO. TYPE STATE EXPIRATION LICENSE NO. TYPE STATE EXPIRATION A. HAVE YOU EVER BEEN DENIED A LICENSE, PERMIT OR PRIVILEGE TO OPERATE A MOTOR VEHICLE? YesNo B. HAS A LICENSE, PERMIT OR PRIVILEGE EVER BEEN SUSPENDED OR REVOKED? YesNo IF THE ANSWER TO A OR B IS YES, GIVE DETAILS HAVE YOU EVER REFUSED OR FAILED AN ALCOHOL TEST WITH A RESULT OF 0.04 OR HIGHER DURING THE PAST 2 YEARS? YesNo HAVE YOU EVER TESTED POSITIVE, REFUSED, ADULTERATED OR SUBSTITUTED A TEST SPECIMEN FOR CONTROLLED SUBSTANCES DURING THE PAST 2 YEARS? YesNo DRIVING EXPERIENCE STRAIGHT TRUCK YesNo TYPE OF EQUIPMENT Van Tank Flat Dump Refer DATES (FROM-TO) APPROX # OF MILES (TOTAL) TRACTOR/ SEMI TRAILER YesNo TYPE OF EQUIPMENT Van Tank Flat Dump Refer DATES (FROM-TO) APPROX # OF MILES (TOTAL) TRACTOR/ TWO TRAILERS YesNo TYPE OF EQUIPMENT Van Tank Flat Dump Refer DATES (FROM-TO) APPROX # OF MILES (TOTAL) TRACTOR / THREE TRAILERS YesNo TYPE OF EQUIPMENT Van Tank Flat Dump Refer DATES (FROM-TO) APPROX # OF MILES (TOTAL) MOTOR COACH - SCHOOL BUS (MORE THAN 8 PASSENGERS) YesNo DATES (FROM-TO) APPROX # OF MILES (TOTAL) MOTOR COACH - SCHOOL BUS (MORE THAN 15 PASSENGERS) YesNo DATES (FROM-TO) APPROX # OF MILES (TOTAL) OTHER DATES (FROM-TO) APPROX # OF MILES (TOTAL) LIST STATES OPERATED IN FOR LAST FIVE YEARS WHAT YEAR DID YOU BEGIN DRIVING A COMMERCIAL MOTOR VEHICLE? ACCIDENT RECORD- For past 3 years (attach sheet if more space is needed). LAST ACCIDENT DATE NATURE OF ACCIDENT (HEAD-ON, REAR-END, ETC.) FATALITIES INJURIES HAZARDOUS MATERIAL SPILL NEXT PREVIOUS NATURE OF ACCIDENT FATALITIES INJURIES HAZARDOUS MATERIAL SPILL NEXT PREVIOUS NATURE OF ACCIDENT FATALITIES INJURIES HAZARDOUS MATERIAL SPILL TRAFFIC CONVICTIONS and forfeitures for the past 3 years (other than parking violations). LOCATION DATE CHARGE PENALTY LOCATION DATE CHARGE PENALTY LOCATION DATE CHARGE PENALTY Employment History (You must provide employment history for 10 complete years) EMPLOYER NAME ADDRESS CITY/STATE ZIP PHONE # CONTACT PERSON DATES (FROM-TO) POSITION SALARY REASON FOR LEAVING WERE YOU SUBJECT TO THE FEDERAL MOTOR CARRIER SAFETY REGULATIONS WHILE EMPLOYED? YesNo WAS YOUR JOB DESIGNATED AS A SAFETY SENSITIVE FUNCTION IN ANY DOT-REGULATED MODE SUBJECT TO THE DRUG AND ALCOHOL TESTING REQUIREMENTS OF 49 CFR PART 40? YesNo EMPLOYER NAME ADDRESS CITY/STATE ZIP PHONE # CONTACT PERSON DATES (FROM-TO) POSITION SALARY REASON FOR LEAVING WERE YOU SUBJECT TO THE FEDERAL MOTOR CARRIER SAFETY REGULATIONS WHILE EMPLOYED? YesNo WAS YOUR JOB DESIGNATED AS A SAFETY SENSITIVE FUNCTION IN ANY DOT-RELATED MODE SUBJECT TO THE DRUG AND ALCOHOL TESTING REQUIREMENTS OF 49 CFR PART 40? YesNo EMPLOYER NAME ADDRESS CITY/STATE ZIP PHONE # CONTACT PERSON DATES (FROM-TO) POSITION SALARY REASON FOR LEAVING WERE YOU SUBJECT TO THE FEDERAL MOTOR CARRIER SAFETY REGULATIONS WHILE EMPLOYED? YesNo WAS YOUR JOB DESIGNATED AS AS SAFETY SENSITIVE FUNCTION IN ANY DOT-RELATED MODE SUBJECT TO THE DRUG AND ALCOHOL TESTING REQUIREMENTS OF 49 CFR 40? YesNo EMPLOYER NAME ADDRESS CITY/STATE ZIP PHONE # CONTACT PERSON DATES (FROM-TO) POSITION SALARY REASON FOR LEAVING WERE YOU SUBJECT TO THE FEDERAL MOTOR CARRIER SAFETY REGULATIONS WHILE EMPLOYED? YesNo WAS YOUR JOB DESIGNATED AS A SAFETY SENSITIVE FUNCTION IN ANY DOT-RELATED MODE SUBJECT TO THE DRUG AND ALCOHOL TESTING REQUIREMENTS OF 49 CFR 40? YesNo INCLUDES VEHICLES HAVING A GVWR OF 26,001 LBS OR MORE, VEHICLES DESIGNED TO TRANSPORT 16 OR MORE PASSENGERS (INCLUDING THE DRIVER), OR ANY SIZE VEHICLE USED TO TRANSPORT HAZARDOUS MATERIALS IN A QUANTITY REQUIRING PLACARDING. THE FEDERAL MOTOR CARRIER SAFETY REGULATIONS (FMCSR’S) APPLY TO ANYONE OPERATING A MOTOR VEHICLE ON A HIGHWAY IN INTERSTATE OR INTRASTATE COMMERCE TO TRANSPORT PASSENGERS OR PROPERTY WHEN THE VEHICLE: (1) WEIGHS OR HAS A GVWR OF 10,0001 LBS. OR MORE, (2) IS DESIGNED OR USED TO TRANSPORT MORE THAN 8 PASSENGERS (INCLUDING THE DRIVER), OR (3) IS OF ANY SIZE AND IS USED TO TRANSPORT HAZARDOUS MATERIALS IN A QUANTITY REQUIRING PLACARDING. EMPLOYER NAME ADDRESS CITY/STATE ZIP PHONE # CONTACT PERSON DATES (FROM-TO) POSITION SALARY REASON FOR LEAVING WERE YOU SUBJECT TO THE FEDERAL MOTOR CARRIER SAFETY REGULATIONS WHILE EMPLOYED? YesNo WAS YOUR JOB DESIGNATED AS A SAFETY SENSITIVE FUNCTION IN ANY DOT-RELATED MODE SUBJECT TO THE DRUG AND ALCOHOL TESTING REQUIREMENTS OF 49 CFR 40? YesNo EMPLOYER NAME ADDRESS: CITY/STATE: ZIP PHONE # CONTACT PERSON DATES (FROM-TO) POSITION SALARY REASON FOR LEAVING WERE YOU SUBJECT TO THE FEDERAL MOTOR CARRIER SAFETY REGULATIONS WHILE EMPLOYED? YesNo WAS YOUR JOB DESIGNATED AS A SAFETY SENSITIVE FUNCTION IN ANY DOT-RELATED MODE SUBJECT TO THE DRUG AND ALCOHOL TESTING REQUIREMENTS OF 49 CFR 40? YesNo EMPLOYER NAME ADDRESS CITY/STATE: ZIP PHONE # CONTACT PERSON DATES (FROM-TO) POSITION SALARY REASON FOR LEAVING WERE YOU SUBJECT TO THE FEDERAL MOTOR CARRIER SAFETY REGULATIONS WHILE EMPLOYED? YesNo WAS YOUR JOB DESIGNATED AS A SAFETY SENSITIVE FUNCTION IN ANY DOT-RELATED MODE SUBJECT TO THE DRUG AND ALCOHOL TESTING REQUIREMENTS OF 49 CFR 40? YesNo IN COMPLIANCE WITH THE FEDERAL AND STATE EQUAL EMPLOYMENT OPPORTUNITY LAWS, QUALIFIED APPLICANTS ARE CONSIDERED FOR ALL POSITIONS WITHOUT REGARD TO RACE, COLOR, RELIGION, SEX, NATIONAL ORIGIN, AGE, MARITAL STATUS, VETERAN STATUS, NON-JOB RELATED DISABILITY, OR ANY OTHER PROTECTED GROUP STATUS. I AUTHORIZE YOU TO MAKE SUCH INVESTIGATIONS AND INQUIRIES OF MY PERSONAL, EMPLOYMENT, FINANCIAL OR MEDICAL HISTORY AND OTHER RELATED MATTERS AS MAY BE NECESSARY IN ARRIVING AT AN EMPLOYMENT DECISION. (GENERALLY, INQUIRIES REGARDING MEDICAL HISTORY WILL BE MADE ONLY IF AND AFTER A CONDITIONAL OFFER OF EMPLOYMENT HAS BEEN EXTENDED.) I HEREBY RELEASE EMPLOYERS, SCHOOLS, HEALTHCARE 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 UNDERSTAND, ALSO, THAT I AM REQUIRED TO ABIDE BY ALL RULES AND REGULATIONS OF THE COMPANY. IF NECESSARY FOR EMPLOYMENT, I MAY BE REQUIRED TO: SUPPLY MY BIRTH CERTIFICATE OR OTHER PROOF OF AUTHORIZATION TO WORK IN THE U.S., HAVE A PHYSICAL EXAMINATION AND/OR DRUG TEST, OR TO SIGN A CONFLICT OF INTEREST AGREEMENT AND ABIDE BY ITS TERMS. I UNDERSTAND THAT THE INFORMATION I PROVIDE REGARDING CURRENT/AND OR PREVIOUS 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(D) AND (E). I UNDERSTAND THAT I HAVE THE RIGHT TO? REVIEW INFORMATION PROVIDED BY PREVIOUS EMPLOYERS, HAVE ERRORS IN THE INFORMATION CORRECTED BY PREVIOUS EMPLOYERS AND FOR THOSE PREVIOUS EMPLOYERS TO RE-SEND THE 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. I UNDERSTAND AND AGREE TO THE INFORMATION SHOWN ABOVE. SIGNATURE OF APPLICANT DATE SOUTHERN TRANSPORT LLC HAS MY PERMISSION TO REQUEST A COPY OF MY MOTOR VEHICLE RECORD, RUN A BACKGROUND CHECK, AND VERIFY MY SOCIAL SECURITY NUMBER FOR EMPLOYMENT PURPOSES. FULL NAME SOCIAL SECURITY # DATE OF BIRTH 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 SOUTHERN TRANSPORT LLC (“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 SOUTHERN TRANSPORT LLC (“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 SIGNATURE 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. 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