First Name
Middle Name
Last Name
Other Name(s)
Social Security Number (SSN)
Date of Birth
Applicant accepted terms?YesNo
Address (Current)
City
State
Zip Code
Phone
Email
Lived at this residence for 3 years or more?YesNo
Position Applied For
Legally eligible to work in the U.S.?YesNo
Do you read, write, and speak English?YesNo
Do you have a TWIC Card?YesNo
How did you hear about us?
Date available for work
Experience Driving Straight Trucks?
Experience Driving Tractor and Semi-Trailer?
Type of Trailer
License Class
License Number
License State
License Expiration
Endorsements?YesNo
DoubleYesNo
TankYesNo
Tank Hazmat YesNo
Passenger YesNo
School Bus YesNo
Had more than one month of unemployment?YesNo
Employer Name
Start Date
End Date
Is this your current employer?YesNo
Position Held
Street Address
Country
Fax
Reason for Leaving
Did you operate a commercial motor vehicle?YesNo
While employed here, were you subject to the Federal Motor Carrier Safety Regulations? YesNo
Was the job designated as a safety sensitive function in any Department of Transportation regulated mode subject to alcohol and controlled substance testing requirements as required by 49 CFR Part 40? YesNo
Employer 2 Yes
Is this your current employer? YesNo
Was the job designated as a safety sensitive function in any Department of Transportation regulated mode subject to alcohol and controlled substance testing requirements as required by 49 CFR Part 40?YesNo
Were you ever in the military? YesNo
Have you ever been denied a license, permit, or privilege to operate a motor vehicle?YesNo
Reason:
Has any license, permit, or privilege ever been suspended or revoked?YesNo
Did you ever have any drug and alcohol positive test or refusals? YesNo
California: Under California Civil Code §1786.22, you may view the file maintained by the CRA during business hours. Additionally, you may obtain a copy of this file, with proper identification, in person at the CRA’s office, by certified mail, or by telephone. If you appear in person, you are permitted to be accompanied by one other person of your choosing, who shall also furnish proper identification. A summary of your rights under §1786.22 are available here on this document as an additional section.
Maine: Upon request, you have the right to be informed of whether an investigative consumer report was requested, and if so, the name and address of the CRA providing the report and within five business days of receipt of your request the name, address, and telephone number of the nearest unit designated to handle requests for your CRA. Additionally, you have the right to request and promptly receive a copy of any report furnished by the CRA.
New Jersey: The state of New Jersey Fair Credit Reporting Act (NJFCRA) is designed to promote accuracy, fairness, consumer confidentiality and the proper use of credit data by each CRA in accordance with the requirements of the NJFCRA. The NJFCRA is modeled after the Federal Fair Credit Reporting Act and the two Acts are almost identical, as are your rights under them. You have received A Summary of Your Rights Under the Federal FCRA. You can find the complete text of the NJFCRA at the Department of Consumer Affairs. You may seek damages from violators. If a CRA, a user or (in some cases) a provider of CRA data violates the NJFCRA, you may sue them in court. For questions or concerns regarding the NJFCRA, please contact: Division of Consumer Affairs, Department of Law and Public Safety, 124 Halsey Street, Newark, NJ 07102, Phone: 800-242-5846 or 973-504-6200.
New York: Upon request, you have the right to be informed of whether an investigative consumer report was requested, and if so, the name and address of the CRA providing the report. You may inspect and receive a copy of the report by contacting the CRA. A copy of New York Correction Law Article 23-A is being provided to you here on this document as an additional section.
Washington: The State of Washington Fair Credit Reporting Act (WFCRA) is designed to promote accuracy, fairness, consumer confidentiality and the proper use of credit data by each CRA in accordance with the requirements of the WFCRA. The WFCRA is modeled after the Federal Fair Credit Reporting Act and two Acts are almost identical as are your rights under them. You have received a Summary of Your Rights under the Federal FCRA. You can find the complete text of WFCRA RCW 19.182, at the nearest office of the Washington State Attorney General. You may seek damages from violators. If a CRA, a user or (in some cases) a provider of CRA data violates the WFCRA, you may sue them in court. For questions or concerns regarding the WFCRA, please contact: Attorney General of the State of Washington, 1125 Washington Street S. E., P.O. Box 40100, Olympia, WA 98504-0100, Phone: 360-753-6200.
NEW YORK CORRECTION LAW ARTICLE 23-A
LICENSURE AND EMPLOYMENT OF PERSONS PREVIOUSLY CONVICTED OF ONE OR MORE CRIMINAL OFFENSESSection 750. Definitions.
751. Applicability.
752. Unfair discrimination against persons previously convicted of one or more criminal offenses prohibited.
753. Factors to be considered concerning a previous criminal conviction; presumption.
754. Written statement upon denial of license or employment.
755. Enforcement.
§750. Definitions. For the purposes of this article, the following terms shall have the following meanings:
(1) "Public agency" means the state or any local subdivision thereof, or any state or local department, agency, board or commission.
(2)"Private employer" means any person, company, corporation, labor organization or association which employs ten or more persons.
(3) "Direct relationship" means that the nature of criminal conduct for which the person was convicted has a direct bearing on his fitness or ability to perform one or more of the duties or responsibilities necessarily related to the license, opportunity, or job in question.
(4) "License" means any certificate, license, permit or grant of permission required by the laws of this state, its political subdivisions or instrumentalities as a condition for the lawful practice of any occupation, employment, trade, vocation, business, or profession. Provided, however, that "license" shall not, for the purposes of this article, include any license or permit to own, possess, carry, or fire any explosive, pistol, handgun, rifle, shotgun, or other firearm.
(5) "Employment" means any occupation, vocation or employment, or any form of vocational or educational training. Provided, however, that "employment" shall not, for the purposes of this article, include membership in any law enforcement agency.
§751. Applicability. The provisions of this article shall apply to any application by any person for a license or employment at any public or private employer, who has previously been convicted of one or more criminal offenses in this state or in any other jurisdiction, and to any license or employment held by any person whose conviction of one or more criminal offenses in this state or in any other jurisdiction preceded such employment or granting of a license, except where a mandatory forfeiture, disability or bar to employment is imposed by law, and has not been removed by an executive pardon, certificate of relief from disabilities or certificate of good conduct. Nothing in this article shall be construed to affect any right an employer may have with respect to an intentional misrepresentation in connection with an application for employment made by a prospective employee or previously made by a current employee.
§752. Unfair discrimination against persons previously convicted of one or more criminal offenses prohibited. No application for any license or employment, and no employment or license held by an individual, to which the provisions of this article are applicable, shall be denied or acted upon adversely by reason of the individual's having been previously convicted of one or more criminal offenses, or by reason of a finding of lack of "good moral character" when such finding is based upon the fact that the individual has previously been convicted of one or more criminal offenses, unless:
(1) There is a direct relationship between one or more of the previous criminal offenses and the specific license or employment sought or held by the individual; or
(2) the issuance or continuation of the license or the granting or continuation of the employment would involve an unreasonable risk to property or to the safety or welfare of specific individuals or the general public.
§753. Factors to be considered concerning a previous criminal conviction; presumption.
In making a determination pursuant to section seven hundred fifty-two of this chapter, the public agency or private employer shall consider the following factors:
(a) The public policy of this state, as expressed in this act, to encourage the licensure and employment of persons previously convicted of one or more criminal offenses.
(b) The specific duties and responsibilities necessarily related to the license or employment sought or held by the person.
(c) The bearing, if any, the criminal offense or offenses for which the person was previously convicted will have on his fitness or ability to perform one or more such duties or responsibilities.
(d) The time which has elapsed since the occurrence of the criminal offense or offenses.
(e) The age of the person at the time of occurrence of the criminal offense or offenses.
(f) The seriousness of the offense or offenses.
(g) Any information produced by the person, or produced on his behalf, in regard to his rehabilitation and good conduct.
(h) The legitimate interest of the public agency or private employer in protecting property, and the safety and welfare of specific individuals or the general public.
In making a determination pursuant to section seven hundred fifty-two of this chapter, the public agency or private employer shall also give consideration to a certificate of relief from disabilities or a certificate of good conduct issued to the applicant, which certificate shall create a presumption of rehabilitation in regard to the offense or offenses specified therein.
§754. Written statement upon denial of license or employment. At the request of any person previously convicted of one or more criminal offenses who has been denied a license or employment, a public agency or private employer shall provide, within thirty days of a request, a written statement setting forth the reasons for such denial.
§755. Enforcement.
In relation to actions by public agencies, the provisions of this article shall be enforceable by a proceeding brought pursuant to article seventy-eight of the civil practice law and rules.
In relation to actions by private employers, the provisions of this article shall be enforceable by the division of human rights pursuant to the powers and procedures set forth in article fifteen of the executive law, and, concurrently, by the New York city commission on human rights.
A Summary of Your Rights Under the Provisions of California Civil Code Section 1786.22
The Investigative Consumer Reporting Agencies Act (ICRAA) is designed to promote accuracy, fairness, and privacy of information in the files of every “investigative consumer reporting agency.” The ICRAA gives you specific rights, including those outlined below. You may have additional rights under federal law.
California Civil Code §1786.10 requires an investigative consumer reporting agency to allow a consumer to visually inspect all files maintained regarding the consumer at the time of the request. Certain information regarding the sources of information used for a report is excluded.
Under California Civil Code §1786.22, an investigative consumer reporting agency shall supply files and information about you, the consumer, during normal business hours and on reasonable notice. The investigative consumer reporting agency will make files maintained on you available for visual inspection in the following ways:
In person, if you appear in person and furnish proper identification. A copy of the file will also be available to you for a fee not to exceed the actual cost of copying.
By certified mail, if you make a written request, with proper identification, for copies to be sent to a specified address. However, agencies complying with a request for such a mailing will not be liable for disclosures to third parties caused by mishandling of mail after it leaves the agency.
By telephone. A summary of all information contained in your file and required to be provided to you under §1786.10 will be provided by telephone, if you have made a written request, with proper identification for telephone disclosure, and the toll charge, if any, for the telephone call is prepaid by or charged directly to you.
“Proper identification” means information generally deemed sufficient to identify a person. This includes documents such as a valid driver’s license, social security account number, military identification card, and credit cards. Only if you are unable to reasonably identify yourself with the information described above, may an investigative consumer reporting agency require additional information concerning your employment and personal or family history in order to verify your identity.
The investigative consumer reporting agency shall also provide trained personnel to explain any information provided to you. The investigative consumer reporting agency shall provide a written explanation of any coded information contained in files maintained on you. This written explanation shall be distributed whenever a file is provided to you for visual inspection as required under §1786.22.
You will be permitted to be accompanied by one other person of your choosing, who shall furnish reasonable identification. The investigative consumer reporting agency may require you to furnish a written statement granting permission to the agency to discuss your file in such person’s presence.
In connection with your application for employment with SHEFFIELD LOGISTICS LLC (“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 in the 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.
If you agree that the Prospective Employer may obtain such background reports, please read the following and sign below:
I authorize SHEFFIELD LOGISTICS 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.
SSN:
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.
I hereby provide consent to SHEFFIELD LOGISTICS LLC (“Prospective Employer”) to conduct a limited query of the FMCSA Commercial Driver’s License Drug and Alcohol Clearinghouse (Clearinghouse) to determine whether drug or alcohol violation information about me exists in the Clearinghouse.
I understand that if the limited query conducted by Prospective Employer indicates that drug or alcohol violation information about me exists in the Clearinghouse, FMCSA will not disclose that information to Prospective Employer without first obtaining additional specific consent from me.
I further understand that if I refuse to provide consent for Prospective Employer to conduct a limited query of the Clearinghouse, Prospective Employer must prohibit me from performing safety-sensitive functions, including driving a commercial motor vehicle, as required by FMCSA’s drug and alcohol program regulations.
I understand that by providing consent and if employed by Prospective Employer, I allow Prospective Employer to run additional queries as required for the duration of my employment with Prospective Employer.
I,
Hereby authorize:
Previous Employer:
Email:
Street:
Telephone:
City:
State:
ZIP:
Fax No:
To release and forward the information requested by section 3 of this document concerning my Alcohol and Controlled Substances Testing records within the previous 3 years from _________________
Prospective Employer:
In compliance with §40.25(g) and 391.23(h), release of this information must be made in a written form that ensures confidentiality, such as fax, email, or letter.
Prospective employer's fax number:
Prospective employer's email address:
As part of my participation with LogRock and submitting an application(s) to SHEFFIELD LOGISTICS LLC (“Prospective Employer”), I will receive all documentation, including but not limited to, consent documentation by electronic means.
In order to obtain, download and all documentation I must have the following hardware or software in place:
A personal computer capable of receiving, accessing, and displaying or printing or storing communications received from LogRock or a Prospective Employer in an electronic form. Adobe PDF Reader version. A mobile smart phone with internet capabilities. Google Chrome, Mozilla Firefox, Microsoft Edge, or Apple Safari internet browser. By accepting electronic documentation, I affirm that my computer system meets the hardware and software requirements necessary requirements for receiving related documents.
It is my responsibility to download and store all documents made available to me through LogRock or Prospective Employer. LogRock may at its sole discretion discontinue availability of this site at any time, without further notice.
By accepting and/or inserting my signature, I hereby consent under the terms herein to this agreement to the electronic delivery of documents and the use of my electronic signature to execute all documents. I understand that my electronic signature will have the same legal effect, validity, and enforceability as if I were to execute by handwritten signature.
In connection with your employment application and for other employment purposes, SHEFFIELD LOGISTICS LLC (“Prospective Employer”) may seek background information about you from a consumer reporting agency. This information will be in the form of consumer reports.
These reports may be obtained at any time after Prospective Employer receives authorization from you, including any time during the period of your employment if Prospective Employer hires you.
Consumer reports include any written, oral, or other communication of information by a consumer reporting agency bearing on your credit standing, character, general reputation, and other personal characteristics that is expected to be used for employment purposes. Consumer reports may include credit reports, criminal records, and driving records, among other resources.
SHEFFIELD LOGISTICS LLC or another consumer reporting agency (“CRA”), will obtain the reports for Prospective Employer.
You have the right to request information from Prospective Employer about the nature and scope of any investigative consumer report on you that is requested by Prospective Employer. The request must be made in writing and within a reasonable period of time after you have received this disclosure.
A summary of your rights under the federal Fair Credit Reporting Act (FCRA) is being provided to you here.
Additional State Law Notices
If you are a California, Maine, New Jersey, New York or Washington applicant, additional notices are provided below.
By signing below, I certify that the information provided on this form is true and correct. I understand that any information that I provide in an employment application or that I otherwise disclose during my employment may be used to obtain consumer reports.
SEVEN-DAY PRIOR LOG FORM
(Data sheet for new, casual, or temporary drivers)
Section 395.8(j)(2) Motor carriers, when using a driver for the first time or intermittently, shall obtain from the driver a signed statement giving the total time on duty during the immediately preceding 7 days and the time at which the driver was last relieved from duty prior to beginning work for the motor carriers.
Section 395.8(k)(2) The driver shall retain a copy of each record of duty status for the previous 7 consecutive days which shall be in his/her possession and available for inspection while on duty.
Instructions: In the spaces below, show the number of hours worked (on duty) in each of the last 7 days.
DAY
1
2
3
4
5
6
7
TOTAL
DATE
HOURS WORKED
I hereby certify that the information given above is correct to the best of my knowledge and belief. And that I was last relieved from work at:
Time
Day
Month
Year
Name:
Signature:
Date:
