U.S. Road Driver Application

Please list all addresses of residence in the last 3 years.

Street Address:

City:

State:

Zip:

End Date:
Start Date:

Month January February March April May June July August September October November December

Note:

If you have lived at current residence for less than 3 years (date), another form will be required below before you may continue. To edit previous dates you must delete the forms under it.

Delete Address

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Add Address

List all traffic accidents in which you were involved, regardless of fault, for the last 3 years.

Date of accident:

Month January February March April May June July August September October November December

Nature of accident:

Number of fatalities:
0
1
2
3
4+

Number of injuries:
0
1
2
3
4+

Was it DOT recordable:
Yes
No

Was it preventable:
Yes
No

Was it chargeable:
Yes
No

Delete Accident Record

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Add Accident Record

Check if none:

List all traffic convictions and forfeitures for the last 3 years (other than parking violations).

Date of incident:

Month January February March April May June July August September October November December

State:

Violation:

Penalty:

Delete Traffic Incident

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Add Traffic Incident

Check if none:

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.

Please upload a picture of the front of your driver's license.

Upload Image

Please upload a picture of the back of your driver's license.

Upload Image

List all of your CDL endorsements (check all that apply):

Hazmat

Doubles/Triples

Tanker

State:

License Number:

Type/Class:

Expiration Date:

Month January February March April May June July August September October November December

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State:

License Number:

Type/Class:

Expiration Date:

Month January February March April May June July August September October November December

Delete License

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Add License

The Federal Motor Carrier Safety Regulations (49 CFR 391.21) require that all applicants who have driven a commercial vehicle previously must provide employment history for a total of 10 years. Please explain any gaps in employment.

Start with the last or current position, including any periods of unemployment and military experience, and work backwards.

Employer Name:

Street Address:

City:

State:

Phone Number:

Position:

Reason for Leaving:

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

End Date:
Start Date:

Month January February March April May June July August September October November December

Note:

If the above period does not start on or before {date 10 years ago}, another form will be required below before you may continue. To edit previous dates you must delete the forms under it.

Delete Form

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Explain gap in employment:

End Date:
Start Date:

Month January February March April May June July August September October November December

Note:

If the above period does not start on or before {date 10 years ago}, another form will be required below before you may continue. To edit previous dates you must delete the forms under it.

Delete Form

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Add Employment Add Unemployment

Please list all of your driving experience.

Type of Equipment Straight Truck Tractor & Semi-Trailer Tractor & 2 Trailers Tractor & Tanker Other

Start Date:

Month January February March April May June July August September October November December

End Date:

Month January February March April May June July August September October November December

Approximate Number of Miles:

Delete Driving Experience

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Add Driving Experience

Check if none:

I herby authorize U.S. Road Freight Express, Inc. to obtain my driver's license record and/or vehicle registration information, including my personal information on those records.

Today's Date: (today's date)

Name: (first name) (middle initial) (last name)

Date of Birth: (date of birth)

Social Security Number: (ss number)

Drivers License Number: (date of birth)

Signature: Add/Edit Signature

Sign below

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I, (first name) (middle initial) (last name), hereby authorize U.S. Road Freight Express, Inc. to contact all previous employers for the last 3 years for the purpose of investigating my safety performance history as required by 49 CFR 391.23.

Today's Date: (today's date)

Name: (first name) (middle initial) (last name)

Date of Birth: (date of birth)

Social Security Number: (ss number)

Signature: Click To Add Signature

Important Disclosure

Regarding Background Reports From The PSP Online Service

In connection with your application for employment with U.S. Road Freight Express, Inc. ("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 U.S. Road Freight Express, Inc. ("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.

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.

Today's Date: (today's date)

Name: (first name) (middle initial) (last name)

Signature: Click To Add Signature

I understand that in the event I am hired by U.S. Road Freight Express, Inc. and am terminated (either voluntarily or involuntarily) within the first 6 months, any costs incurred by U.S. Road Freight Express, Inc. may be withheld from my final paycheck. These costs include, but are not limited to, physical examinations, drug screens, business cards, uniforms, and any items issued to me that are not returned or returned damaged.

I understand that in the event I am hired and am involved in a preventable accident during the 6-month probation period, it will be cause for termination of employment from U.S. Road Freight Express, Inc. I further understand that if I am involved in a non-preventable accident during the 6-month probation period, violate company policies, violate local, state or federal laws or regulations, it may also be cause for termination.

Today's Date: (today's date)

Name: (first name) (middle initial) (last name)

Signature: Click To Add Signature

I authorize U.S. Road Freight Express, Inc. 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.

I understand no offer of employment may be tendered, nor may employment commence, until the controlled substances test has been taken and U.S. Road Freight has been advised of the results, which must be negative. I agree to submit to the controlled substances testing via the prescribed testing methods at the site selected by U.S. Road Freight on the appointed date and time. I also understand my employment will be conditioned on the results of a physical examination, which I must pass.

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 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 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.

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.

Today's Date: (today's date)

Name: (first name) (middle initial) (last name)

Signature: Click To Add Signature