LICENSE INFORMATION

LIST ALL DRIVER LICENSES OR PERMITS HELD IN LAST 3 YEARS

Section 383.21 FMCSR states "No person who operates a commercial vehicle shall at any time have more than one driver license". I certify that I do not have more than one motor vehicle license, the information for which is listed below.

PREVIOUS ADDRESSES FOR THE PAST THREE (3) YEARS

Please fill out the fields below

YEAR 1

Address

ACCIDENT RECORD FOR THE PAST 3 YEARS OR MORE

IF NONE SELECT "NONE"

TRAFFIC CONVICTIONS AND FORFEITURES FOR THE PAST 3 YEARS (OTHER THEN PARKING VIOLATIONS)

IF NONE SELECT "NONE"

In accordance with 391.21 & .23 of the Federal Motor Carrier Safety Regulations (FMCSR), an applicant must list all of their previous work experience for the ten (10) years prior to the date of application shown on page one, preferably all commercial driving experience for the previous ten (10) years.

PLEASE LIST STARTING WITH THE MOST RECENT EMPLOYER

CURRENT OR LAST JOB

Address

The Federal Motor Carrier Safety Regulations apply to anyone operating a motor vehicle on a highway in interstate commerce to transport passengers or property when the vehicle: 1) weighs or has a GVWR of 10,001 pounds or more, 2) is designed or used to transport 9 or more passengers, or 3) is of any size and is used to transport hazardous materials in a requiring pleading.
** Any gaps in employment more than 30 days and/or unemployment must be explained.

*Checking this box certifies that this application was completed by me and that all entries on it and information in it are true and complete to the best of my knowledge. I authorize you to obtain information regarding my previous employment, previous drug and alcohol test results, and my driving record as required by Sections 382.413 and 391.23 of the Federal Motor Carrier Safety Regulations.

This certifies that this application was completed by me, and that all entries on it and information in it are true and complete to the best of my knowledge. By signing below, I agree to use an electronic signature to demonstrate my consent. An electronic signature is as legally binding as an ink signature *

IMPORTANT DISCLOSURE REGARDING BACKGROUND REPORTS FROM THE PSP Online Service

In connection with your application for employment with the "Company" ("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 the "Company" ("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.

Please read over and check the box

* By checking the box, I (a) acknowledge that I have read and understand the PSP Disclosure and Authorization and also have been given the opportunity to copy/print it, and (b) agree to use an electronic signature to demonstrate my consent. An electronic signature is as legally binding as an ink signature.

Signature *

PLEASE READ THE DISCLOSURE AND AUTHORIZATION STATEMENT PRIOR TO SIGNING THIS AUTHORIZATION FORM

I have carefully read and understood this Disclosure and Authorization Statement and the FTC summary of rights under the Fair Credit Reporting Act (“FCRA”). By my signature below, I consent to the release of consumer reports, investigative consumer reports, and other personal history reports prepared by a consumer reporting agency, government agency or department, or other entity to (the “Company”). I understand that if the Company hires me, my consent will apply, and the company may obtain the reports, throughout my employment. I also understand that information contained in my job application or otherwise disclosed by me before or during my employment, if any, may be used for the purpose of obtaining Consumer reports and/or investigative consumer reports. By my signature below, I 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. Furthermore, Customers of the Company may require investigative or consumer reports which apply to my background. These reports would apply to my assessment to projects related to the Customer, permission to be on the Customers premises and to handle its products and other security concerns of the Customer. I agree to allow the Company to provide my work history information to a consumer reporting agency. I understand that I have the right to review information provided by my previous employers, to have errors corrected by the previous employers and re-send to the Company once corrected, and to have a rebuttal statement attached to any alleged erroneous information should my previous employer and I not agree on the accuracy of the information. I further understand that the information provided by me will be used in making employment determinations and that my previous employer will be contacted for the purpose of investigating my safety performance history information as required by paragraphs (d) and (e) of “49 CFR” Part 391.23. Request to review previous employer information must be in writing. A release form for employment records can be requested by calling the supplied number of the “The COMPANY” I understand that I have additional rights under the FCRA as noted in the FTC summary of rights provided to me. I hereby authorize any person or company for whom I have worked (as an employee or contractor), whether listed below or not, to furnish information they may have pertaining to my character, habits, financial responsibility, job performance, reasons for leaving employment, and all information concerning my employment or training. I hereby release all persons and organizations from any claims from damages of any kind. By my signature below, I certify the information I provided on my application is true and correct. I agree that this Disclosure and Authorization form in original, faxed, photocopied or electronic (including electronically signed form) will be valid for any reports that may be requested by or on behalf of the Company.

Please read over and check the box *
* By checking the box, I (a) acknowledge that I have read and understand the Disclosure and Authorization Statement and the FTC summary of rights under the Fair Credit Reporting Act (“FCRA”) and also have been given the opportunity to copy/print it, and (b) agree to use an electronic signature to demonstrate my consent. An electronic signature is as legally binding as an ink signature.

Signature *

DRUG & ALCOHOL CLEARINGHOUSE CONSENT FOR LIMITED QUERIES

NOTICE TO DRIVER: The Commercial Driver’s License (CDL) Drug & Alcohol Clearinghouse is a federal database containing information about CDL drivers who have violated the Federal Motor Carrier Safety Administration’s (FMCSA’s) drug or alcohol regulations in 49 CFR Part 382. Whether you have committed such a violation or not, each motor carrier for whom you drive is required to check whether the Clearinghouse has any information about you, both at the time of hire and annually. When conducting an annual inquiry, the motor carrier has the option to request a “limited” report that only indicates whether the Clearinghouse has any information about you. Before a motor carrier may request a limited report, they must have your written authorization, per §382.701(b). This authorization may be valid for more than one year. If a limited query ever reveals that the Clearinghouse has information about you, you will be required to log in to the Clearinghouse website within 24 hours to grant electronic consent for the motor carrier to obtain your full Clearinghouse record.

NOTICE TO MOTOR CARRIER: This consent form authorizes you to run a “limited query” to
check whether the Clearinghouse has information about the driver identified below. If it does,
then you must obtain a full Clearinghouse record within 24 hours, per §382.701(b). This
consent form must be retained until 3 years after the date of the last limited query you perform
for this driver, based on the authorization below.

AUTHORIZATION

I, , hereby authorize Patriot Freight Incto conduct limited annual queries of the FMCSA’s Drug & Alcohol Clearinghouse, to determine if a Clearinghouse record exists for me. This consent is valid from the date shown below until my employment with the above-named motor carrier ceases or until I am no longer subject to the drug and alcohol testing rules in 49 CFR Part 382 for the above-named motor carrier. I understand that if any limited query reveals that the Clearinghouse contains information about me, I must grant electronic consent within 24 hours, via the Clearinghouse website, for the motor carrier to obtain my full Clearinghouse record. Refusal to provide such consent will result in my removal from safety-sensitive duties.

Signature *

Please leave this field empty.