Company Drivers - Service Transfer Inc.

- Step 1 of 15

Employee Application

Read this cover letter before you complete the application.

Make sure you fill out all parts of the application. You must provide at least 10 years of employment history in accordance with the Federal Highway Administration. DO NOT leave any gaps in your employment. If you were not employed for any period of time, you must provide a reason for the UNEMPLOYMENT. You must also provide at least a telephone number for all of your previous employers.

Any application that is not completely filled out will not be considered for employment.

A written description must be provided for any accident(s) you have on your driving record/PSP and MUST provide a copy of the accident report.

Service Transfer, Inc. is an equal employment opportunity employer. Applicants are considered for all positions without regard to race, color, religion, sex, national origin, age, marital status or non-job related disabilities.

Once your application has been approved you will be required to take and pass a pre-employment drug test. Any test returned with a "negative but diluted" result will not be considered for employment.

Thank you for your interest in employment with SERVICE TRANSFER, INC.

Applicant's Name *

First

Last

Submission Date *

Terminal Location *

Chesapeake, VA
Wilmington, NC
Rocky Mount, NC
Greensboro, NC
Charlotte, NC
Charleston, SC
Savannah, GA
Jacksonville, FL

Area Preference *

Local
Regional
OTR

Note:

In compliance with 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.

Applicant Name *

First Name, Middle Initial, Last Name

Social Security Number *

xxx-xx-xxxx

Email *

Current Address *

Address Line 1

Address Line 2

City

State

Zip Code

Were you at this address 3 years or more? *

If you have lived at the address entered on the previous page for 3+ years, continue to the next page.

Previous Address #1 *

Address Line 1

Address Line 2

City

State

Zip Code

How Long?

How many years/months at this address.

Previous Address #2

Address Line 1

Address Line 2

City

State

Zip Code

How Long?

How many years/months at this address.

Previous Address #3

Address Line 1

Address Line 2

City

State

Zip Code

How Long?

How many years/months at this address.

Home Phone #

Cell Phone # *

Date of Birth *

Required for Commercial Drivers

Present Age *

Current License

Class A License is required.*

License Number *

State of Issue *

License Type/Class *

Endorsements

License Expiration Date *

Previous Licenses Held #1 - Leave Blank if non-applicable

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 in the fields below.

Previous License: License Number

Previous License: State of Issue

Previous License: License Type/Class

Previous License: Endorsements

Previous License: License Expiration Date

Previous Licenses Held #2 - Leave Blank if non-applicable

Previous License: License Number

Previous License: State of Issue

Previous License: License Type/Class

Previous License: Endorsements

Previous License: License Expiration Date

Have you had any other licenses over the past 3 years in addition to the ones listed above? *

Please list any additional licenses information below.

Include license number, state of issue, license type/class, endorsements and license expiration date.

TWIC

Do you have an applicable TWIC Card # ? *

TWIC Card # *

TWIC Expiration Date *

Class of Equipment (Select ALL that apply) *

Straight Truck
Tractor: Semi-Trailer
Tractor: Two Trailers
Other, Not Listed

Type of Equipment (Select ALL that apply) *

Van
Tank
Flat
Dump
Reefer
Container
Other, Not Listed

# of Years with CDL Experience *

Dates Operated & Approx. # of Miles *

From (M/Y) To (M/Y) and total approximate miles

List the states in which you have operated for the past five (5) years *

List area by state in which you are willing to operate *

List any trucking, transportation, or other experience that you would like the company to know about while considering your application.

List any courses and/or training not shown elsewhere in this application that you would like the company to consider.

Accident Record for the past 5 years: If none write NONE §391.21(b)(7) *

Include Dates, Nature of Accident (Head On, Rear End, Etc.), Fatalities and Injuries

Traffic Convictions & License Forfeiture for the past 3 years: (Other than parking violations) If none write NONE 391.21(b)(8) *

Include Location, Dates, Charges and Penalties

Have you ever been denied a license, permit, or privilege to operate a motor vehicle? *

Has any license, permit, or privilege ever been suspended or revoked? *

Have you ever been refused auto liability insurance? *

If you answered Yes to any of these questions, please provide details: §391.21(b)(9) *

Have you ever tested positive or refused any pre-employment drug/alcohol test? *

Have you ever been charged with driving under the influence of alcohol or other controlled substance? *

Have you ever been convicted of possession, sale, or use of a controlled substance? *

If you answered Yes to any of these questions, please provide details: §391.21(b)(9) *

Select Highest Grade Completed *

Highest Level of College Completed *

Last School Attended *

City and State *

Do you have the legal right to work in the United States? *

If yes, can you provide proof? *

Are you HAZMAT certified? *

Have you been trained in the handling procedures of Hazardous Material? *

Have you ever worked for this company before? *

Where? *

Dates *

From / to

Reason for Leaving *

Do you posses a valid U. S. Department of Transportation physical examination long form? *

Date Issued *

Have you ever been convicted of a felony? *

If yes, please explain in full detail. Conviction of a crime is not an automatic bar to employment; all circumstances will be considered. *

Is there any reason you might be unable to perform the functions of the job you are applying for? *

If yes to previous question, please explain. *

All driver applicants who wish to drive a commercial vehicle in the act of interstate commerce MUST provide the following information on ALL employers during the preceding three (3) years. List complete mailing address, street number, city, state and zip code. _{§391.21(b)(10)}

In addition, all driver applicants must provide the following information on all employers for which the applicant drove a commercial motor* vehicle in the act of interstate commerce during the additional preceding seven (7) years._{§391.21(b)(11)}

*Includes vehicles having a GVWR of 26,001 lbs. or more, vehicles designed to transport 15 or more passengers, or any size vehicle used to transport hazardous

Employer Name *

Position Held *

Start Date *

Is this your current employer? *

End Date *

Were you with this employer for more than 3 years? *

City & State *

Contact Person *

Salary/Wage *

Reason for Leaving *

Employer Phone # *

Select ALL That Apply *

Van
Tank
Flat
Dump
Reefer
Container
Other, not listed

Were you subject to Federal Motor Carrier Safety Regulations while employed? §391.21(b)(10)(iv)(A) *

Was your job designated as a safety sensitive function in any DOT regulated mode subject to alcohol and controlled substances testing requirements as required by 49 CFR part40? §391.21(b)(10)(iv)(B) *

May we contact this employer at this time?

If you have been employed with your employer for 3+ years, please continue to the next section.

Employer Name *

Position Held *

Start Date *

End Date *

Were you with this employer for more than 3 years? *

City & State *

Contact Person *

Salary/Wage

Reason for Leaving

Employer Phone

Select ALL That Apply *

Van
Tank
Flat
Dump
Reefer
Container
Other, not listed

Were you subject to Federal Motor Carrier Safety Regulations while employed? §391.21(b)(10)(iv)(A) *

Is this your current employer?

May we contact this employer at this time?

If you have been employed with the previously listed employer for 3+ years, please continue to the next section.

Employer Name *

Position *

Start Date *

End Date *

City & State *

Contact Person

Salary/Wage

Reason for Leaving

Employer Phone

Select ALL That Apply *

Van
Tank
Flat
Dump
Reefer
Container
Other, not listed

Were you subject to Federal Motor Carrier Safety Regulations while employed? §391.21(b)(10)(iv)(A) *

Is this your current employer?

May we contact this employer at this time?

If you need additional space for past employment, please enter it here and include ALL information previously asked for.

Previous Employment Check Authorization *

Agree

I hereby authorize my previous employer(s) to release information to Service Transfer, Inc. regarding my employment history for the purposes of investigation as required by sections 391.23, and drug and alcohol testing results as required by section 40.25 & 382.405 (f) and (h) of the Federal Motor Carrier Safety Regulations. I release the parties involved from any and all liability, which may result from furnishing such information.

Disclosure and Authorization Regarding Background Investigation for Employment Purposes

DISCLOSURE AND AUTHORIZATION REGARDING BACKGROUND INVESTIGATION FOR EMPLOYMENT PURPOSES *

I hereby authorize Service Transfer, Inc. to obtain the consumer reports described below about me.

Disclosure

Service Transfer, Inc. may request from a consumer reporting agency and for employment-related purposes, a “consumer report(s)” (commonly known as “background reports”) containing background information about you in connection with your employment, or application for employment, or engagement for services (including independent contractor or volunteer assignments, as applicable).

HireRight, LLC (“HireRight”) will prepare or assemble the background reports for the Company. HireRight is located and can be contacted at 3349 Michelson Drive, Suite 150, Irvine, CA 92612, (800) 400-2761, www.hireright.com.

The background report(s) may contain information concerning your character, general reputation, personal characteristics, mode of living, or credit standing. The types of background information that may be obtained include, but are not limited to: criminal history; litigation history; motor vehicle record and accident history; social security number verification; address and alias history; credit history; verification of your education, employment and earnings history; professional licensing, credential and certification checks; drug/alcohol testing results and history; military service; and other information.

Other Disclosures, Acknowledgements and Authorizations Regarding Background Investigation for Employment Purposes

OTHER DISCLOSURES, ACKNOWLEDGMENTS & AUTHORIZATIONS REGARDING BACKGROUND INVESTIGATION FOR EMPLOYMENT PURPOSES *

Applicant Authorization

Disclosures

Investigative Consumer Report: Service Transfer, Inc. may request an investigative consumer report about you from HireRight, LLC (“HireRight”), a consumer reporting agency, in connection with your employment, or application for employment, or engagement for services (including independent contractor or volunteer assignments, as applicable). An “investigative consumer report” is a background report that includes information from personal interviews (except in California, where that term includes background reports with or without information obtained from personal interviews), the most common form of which is checking personal or professional references through personal interviews with sources such as your former employers and associates, and other information sources. The investigative consumer report may contain information concerning your character, general reputation, personal characteristics, mode of living, or credit standing. You may request more information about the nature and scope of an investigative consumer report, if any, by contacting the Company.

Ongoing Authorization: If the Company hires you or contracts for your services, the Company may obtain additional consumer reports and investigative consumer reports about you without asking for your authorization again, throughout your employment or your contract period, as allowed by law.

Additional State Law Notices: Please see the “Additional State Law Notices” for California, Massachusetts, Minnesota, New Jersey, New York, and Washington that are provided below, as applicable. A California disclosure and summary of your rights under California Civil Code Section 1786.22, and a copy of New York Article 23-A, are being provided to you separately.

Summary of Rights under the Fair Credit Reporting Act: A summary of your rights under the Fair Credit Reporting Act is being provided to you separately.

San Francisco Fair Chance Ordinance Official Notice: A copy of the San Francisco Fair Chance Ordinance Official Notice is being provided to you separately.

HireRight Privacy Policy: Information about HireRight’s privacy practices is available at www.hireright.com/Privacy-Policy.aspx.

Acknowledgments & Authorization

I acknowledge that I have received and carefully read and understand the separate “Disclosure and Authorization Regarding Background Investigation for Employment Purposes”; and the separate “Summary of Rights under the Fair Credit Reporting Act” that have been provided to me by the Company. I also acknowledge receipt of and that I have carefully read and understand (as applicable), the separate California Disclosure and Summary of Rights under California Civil Code Section 1786.22; the separate New York Article 23-A; and the separate San Francisco Fair Chance Ordinance Official Notice that have been provided to me.

By my signature below, I authorize the preparation of background reports about me, including background reports that are “investigative consumer reports” by HireRight, and to the furnishing of such background reports to the Company and its designated representatives and agents, for the purpose of assisting the Company in making a determination as to my eligibility for employment or engagement for services (including independent contractor or volunteer assignments, as applicable), promotion, retention or for other lawful employment purposes. I understand that if the Company hires me or contracts for my services, my consent will apply, and the Company may, as allowed by law, obtain from HireRight (or from a consumer reporting agency other than HireRight) additional background reports pertaining to me, without asking for my authorization again, throughout my employment or contract period.

I understand that if the Company obtains a credit report about me, then it will only do so where such information is substantially related to the duties and responsibilities of the position in which I am engaged or for which I am being evaluated.

I understand that information contained in my employment (or contractor or volunteer) application, or otherwise disclosed by me before or during my employment (or contract or volunteer assignment), if any, may be used for the purpose of obtaining and evaluating background reports on me. I also understand that nothing herein shall be construed as an offer of employment or contract for services.

I understand that the information included in the background reports may be obtained from private and public record sources, including without limitation and as appropriate: government agencies and courthouses; educational institutions; and employers. Accordingly, I hereby authorize all of the following, to disclose information about me to the consumer reporting agency and its agents: law enforcement and all other federal, state and local government agencies and courts; educational institutions (public or private); testing agencies; information service bureaus; credit bureaus and other consumer reporting agencies; other public and private record/data repositories; motor vehicle records agencies; my employers; the military; and all other individuals and sources with any information about or concerning me. The information that can be disclosed to the consumer reporting agency and its agents includes, but is not limited to, information concerning my: employment and earnings history; education, credit, motor vehicle and accident history; drug/alcohol testing results and history; criminal history; litigation history; military service; professional licenses, credentials and certifications; social security number verification; address and alias history; and other information.

By my signature below, I also promise that the personal information I provide with this form or otherwise in connection with my background investigation is true, accurate and complete, and I understand that dishonesty or material omission may disqualify me from consideration for employment. I agree that a copy of this document in faxed, photocopied or electronic (including electronically signed) form will be valid like the signed original. I further acknowledge that I have received additional state law notices that I have reviewed and read.

Additional State Law Notices

Please also note the following:

CALIFORNIA: Pursuant to section 1786.22 of the California Civil Code, you may view the file maintained on you by the consumer reporting agency during normal business hours. You may also obtain a copy of this file, upon submitting proper identification and paying the actual copying costs, by appearing at the consumer reporting agency’s offices in person, during normal business hours and on reasonable notice, or by certified mail. You may also receive a summary of the file by telephone, upon submitting proper identification and written request. The consumer reporting agency has trained personnel available to explain your file to you, including any coded information, and will provide a written explanation of any coded information contained in your file. If you appear in person, you may be accompanied by one other person, provided that person furnishes proper identification. “Proper identification” includes documents such as a valid driver’s license, social security account number, military identification card, and credit cards. If you cannot identify yourself with such information, the consumer reporting agency may require additional information concerning your employment and personal or family history to verify your identity.

HireRight, LLC (“HireRight”) will prepare the background report for the Company. HireRight is located and can be contacted at 3349 Michelson Drive, Suite 150, Irvine, CA 92612, (800) 400-2761. Information about HireRight’s privacy practices is available at www.hireright.com/Privacy-Policy.aspx.

Additional California-specific information is set out below.

MASSACHUSETTS: Upon request to the Company, you have the right to know whether the Company requested an investigative consumer report about you and, upon written request to the Company, you have the right to receive a copy of any such report. You also have the right to ask the consumer reporting agency (e.g., HireRight) for a copy of any such report.

MINNESOTA: You have the right in most circumstances to submit a written request to the consumer reporting agency (e.g., HireRight) for a complete and accurate disclosure of the nature and scope of any consumer report the Company ordered about you. The consumer reporting agency must provide you with this disclosure within 5 days after (i) its receipt of your request or (ii) the date the report was requested by the Company, whichever date is later.

NEW JERSEY: You have the right to submit a request to the consumer reporting agency (e.g., HireRight) for a copy of any investigative consumer report the Company requested about you.

NEW YORK: You have the right, upon written request to the Company, to be informed of whether or not the Company requested a consumer report or an investigative consumer report about you. Shown above is the address and telephone number for HireRight, the consumer reporting agency used by the Company. You may inspect and receive a copy of any such report by contacting that consumer reporting agency. A copy of Article 23-A of the New York Correction Law is also provided below.

WASHINGTON STATE: If the Company requests an investigative consumer report, you have the right, upon written request made to the Company within a reasonable period of time after your receipt of this disclosure, to receive from the Company a complete and accurate disclosure of the nature and scope of the investigation requested by the Company. You are entitled to this disclosure within 5 days after the date your request is received or the Company ordered the report, whichever is later. You also have the right to request a written summary of your rights and remedies under the Washington Fair Credit Reporting Act.

California, Minnesota or Oklahoma consumers:

Please check this box if you would like to receive (whenever you have such right under the applicable state law) a free copy of your background report if one is obtained on you by the Company.

Important Disclosure Regarding Background Reports from the PSP Online Service

REGARDING BACKGROUND REPORTS FROM THE PSP Online Service *

Applicant Authorization regarding background reports from the PSP Online Service

In connection with your application for employment with Service Transfer, Inc., 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 Service Transfer, Inc. 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.

Attention CDL Drivers: Information Regarding the Drug & Alcohol Clearinghouse

Clearinghouse Evaluation Agreement *

Applicant Agrees to Clearinghouse Evaluation

What is it? An online database providing employers, licensing agencies, and enforcement officers with real-time information about truck and bus drivers who have violated DOT drug or alcohol testing rules. Employers must check the Clearinghouse when hiring each new CDL driver and every year for existing CDL drivers like you. The Clearinghouse will affect you in several ways:

1.) You will need to register on the Clearinghouse website (available Fall 2019) in order to comply with item #2 below. Registration is optional unless you switch employers or have a DOT drug or alcohol violation. Registration will give you free access to your own Clearinghouse record.

2.) You will need to go to the Clearinghouse to grant electronic consent whenever your employer is required to purchase a full Clearinghouse report on you. You will not be allowed to continue operating a commercial motor vehicle (CMV) or perform other safety-sensitive duties if you refuse to grant this consent _{(§382.703(c)}).

3.) You will need to sign a separate consent form (annually or one-time) to allow your employer to obtain “limited” Clearinghouse reports that indicate whether there is information about you in the Clearinghouse (if there is, then a full report will be required – see #2 above) _{(§382.701(b)}).

4.) If you commit any of the following DOT violations or complete any of the following steps after January 6, 2020, it will be reported to the Clearinghouse:

- Any verified positive, adulterated, or substituted drug test
- Any confirmed alcohol test result of 0.04 or higher
- Any refusal to submit to a DOT-required test
- Any verified and documented “actual knowledge” that you violated the drug/alcohol rules:
- Any on-duty alcohol use, including any citation for DUI/DWI while driving a CMV
- Any alcohol use within 4 hours before going on duty
- Any alcohol use within 8 hours of an accident or before a post-accident test is complete (whichever occurs first)
- Any prohibited drug use while on duty
- Successful completion of the return-to-duty process following treatment*
- Any negative return-to-duty test*
- Successful completion of follow-up testing*
*Only reported if the underlying violation occurred after January 6, 2020

5.) You will be notified whenever information about you in the Clearinghouse is added, removed, or revised. You can specify how you want to be contacted when you register.

I hereby acknowledge receiving educational information about the CDL Drug & Alcohol Clearinghouse as required under _{§382.601(b)(12)}.

Drug & Alcohol Clearinghouse Consent for Limited Queries *

Applicant Authorization for Drug & Alcohol Limited QueriesApplicant Authorization for Drug & Alcohol Limited Queries

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.

Service Transfer Inc. is required to check the Clearinghouse when hiring each new CDL driver and every year for existing CDL drivers.

When conducting an annual inquiry, Service Transfer Inc. will have the option to request a Limited report that only indicates whether the Clearinghouse has any information about you; It does not release any violation or testing information. Before pulling a limited query, Service Transfer Inc. must receive written authorization to do so, per _382.701(b).

If a Limited query 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 a Full query of your Clearinghouse record.

Authorization

I hereby authorize Service Transfer Inc. to 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 Service Transfer Inc. ceases or until I am no longer subject to the drug and alcohol testing rules in 49 CFR Part 382 for Service Transfer Inc.

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.

AUTHORIZATION TO OBTAIN MOTOR VEHICLE RECORD

AUTHORIZATION TO OBTAIN MOTOR VEHICLE RECORD *

I hereby authorize Service Transfer Inc to obtain my motor vehicle records

VA Code 46.2-208 classifies driver abstracts as privileged records and limits the release of an abstract of a driver's record to only an employer, potential employer, or authorized agent who has been authorized in writing by such driver to obtain the driver's record.

THE UNDERSIGNED DOES HEREBY ACKNOWLEDGE AND CERTIFY AS FOLLOWS:

1. That the undersigned gives his or her consent to the release of their driving record ("MVR") for review by Service Transfer, Inc

2. That the undersigned authorizes his or her driving record to be periodically obtained and reviewed for the purpose of initial and continued employment.

3. That the undersigned gives his or her consent to the release of their driving record (“MVR") for review by NANSEMOND INSURANCE AGENCY, INC.

4. That the undersigned understands that his or her driving record may also be provided to insurance carriers for the purpose of determining the insurability of certain hazards.

5. That the undersigned authorizes release of and discussion of his or her driving record between potential employees and Nansemond Insurance Agency and any insurance Company.

A Summary of Your Rights Under the Fair Credit Reporting Act

A Summary of Your Rights Under the Fair Credit Reporting Act *

Applicant Agrees to the Summary of Rights Under the Fair Credit Reporting Act

The federal Fair Credit Reporting Act (FCRA) promotes the accuracy, fairness, and privacy of information in the files of consumer reporting agencies. There are many types of consumer reporting agencies, including credit bureaus and specialty agencies (such as agencies that sell information about check writing histories, medical records, and rental history records). Here is a summary of your major rights under FCRA. For more information, including information about additional rights, go to www.consumerfinance.gov/learnmore or write to: Consumer Financial Protection Bureau, 1700 G Street N.W., Washington, DC 20552.

- You must be told if information in your file has been used against you. Anyone who uses a credit report or another type of consumer report to deny your application for credit, insurance, or employment – or to take another adverse action against you – must tell you, and must give you the name, address, and phone number of the agency that provided the information.

- You have the right to know what is in your file. You may request and obtain all the information about you in the files of a consumer reporting agency (your “file disclosure”). You will be required to provide proper identification, which may include your Social Security number. In many cases, the disclosure will be free. You are entitled to a free file disclosure if:

a person has taken adverse action against you because of information in your credit report;

you are the victim of identity theft and place a fraud alert in your file;

your file contains inaccurate information as a result of fraud;

you are on public assistance;

you are unemployed but expect to apply for employment within 60 days.
In addition, all consumers are entitled to one free disclosure every 12 months upon request from each nationwide credit bureau and from nationwide specialty consumer reporting agencies. See www.consumerfinance.gov/learnmore for additional information.

- You have the right to ask for a credit score. Credit scores are numerical summaries of your credit-worthiness based on information from credit bureaus. You may request a credit score from consumer reporting agencies that create scores or distribute scores used in residential real property loans, but you will have to pay for it. In some mortgage transactions, you will receive credit score information for free from the mortgage lender.

- You have the right to dispute incomplete or inaccurate information. If you identify information in your file that is incomplete or inaccurate, and report it to the consumer reporting agency, the agency must investigate unless your dispute is frivolous. See www.consumerfinance.gov/learnmore for an explanation of dispute procedures.

- Consumer reporting agencies must correct or delete inaccurate, incomplete, or unverifiable information. Inaccurate, incomplete, or unverifiable information must be removed or corrected, usually within 30 days. However, a consumer reporting agency may continue to report information it has verified as accurate.

- Consumer reporting agencies may not report outdated negative information. In most cases, a consumer reporting agency may not report negative information that is more than seven years old, or bankruptcies that are more than 10 years old.

- Access to your file is limited. A consumer reporting agency may provide information about you only to people with a valid need – usually to consider an application with a creditor, insurer, employer, landlord, or other business. The FCRA specifies those with a valid need for access.

- You must give your consent for reports to be provided to employers. A consumer reporting agency may not give out information about you to your employer, or a potential employer, without your written consent given to the employer. Written consent generally is not required in the trucking industry. For more information, go to www.consumerfinance.gov/learnmore.

- You may limit “prescreened” offers of credit and insurance you get based on information in your credit report. Unsolicited “prescreened” offers for credit and insurance must include a toll-free phone number you can call if you choose to remove your name and address form the lists these offers are based on. You may opt out with the nationwide credit bureaus at 1-888-5-OPTOUT (1-888-567-8688).

- The following FCRA right applies with respect to nationwide consumer reporting agencies:

CONSUMERS HAVE THE RIGHT TO OBTAIN A SECURITY FREEZE

You have a right to place a “security freeze” on your credit report, which will prohibit a consumer reporting agency from releasing information in your credit report without your express authorization. The security freeze is designed to prevent credit, loans, and services from being approved in your name without your consent. However, you should be aware that using a security freeze to take control over who gets access to the personal and financial information in your credit report may delay, interfere with, or prohibit the timely approval of any subsequent request or application you make regarding a new loan, credit, mortgage, or any other account involving the extension of credit.

As an alternative to a security freeze, you have the right to place an initial or extended fraud alert on your credit file at no cost. An initial fraud alert is a 1-year alert that is placed on a consumer’s credit file. Upon seeing a fraud alert display on a consumer’s credit file, a business is required to take steps to verify the consumer’s identity before extending new credit. If you are a victim of identity theft, you are entitled to an extended fraud alert, which is a fraud alert lasting 7 years.

A security freeze does not apply to a person or entity, or its affiliates, or collection agencies acting on behalf of the person or entity, with which you have an existing account that requests information in your credit report for the purposes of reviewing or collecting the account. Reviewing the account includes activities related to account maintenance, monitoring, credit line increases, and account upgrades and enhancements.

- You may seek damages from violators. If a consumer reporting agency, or, in some cases, a user of consumer reports or a furnisher of information to a consumer reporting agency violates the FCRA, you may be able to sue in state or federal court.

- Identity theft victims and active duty military personnel have additional rights. For more information, visit www.consumerfinance.gov/learnmore.

States may enforce the FCRA, and many states have their own consumer reporting laws. In some cases, you may have more rights under state law. For more information, contact your state or local consumer protection agency or your state Attorney General. For information about your federal rights, contact:

	TYPE OF BUSINESS:	CONTACT:
1.	a. Banks, savings associations, and credit unions with total assets of over $10 billion and their affiliates b. Such affiliates that are not banks, savings associations, or credit unions also should list, in addition to the CFPB:	a. Consumer Financial Protection Bureau 1700 G Street, N.W. Washington, DC 20552 b. Federal Trade Commission Consumer Response Center 600 Pennsylvania Avenue, N.W. Washington, DC 20580 (877) 382-4357
2.	To the extent not included in item 1 above: a. National banks, federal savings associations, and federal branches and federal agencies of foreign banks b. State member banks, branches and agencies of foreign banks (other than federal branches, federal agencies, and Insured State Branches of Foreign Banks), commercial lending companies owned or controlled by foreign banks, and organizations operating under section 25 or 25A of the Federal Reserve Act. c. Nonmember Insured Banks, Insured State Branches of Foreign Banks, and insured state savings associations d. Federal Credit Unions	a. Office of the Comptroller of the Currency Customer Assistance Group 1301 McKinney Street, Suite 3450 Houston, TX 77010-9050 b. Federal Reserve Consumer Help Center P.O. Box 1200 Minneapolis, MN 55480 c. FDIC Consumer Response Center 1100 Walnut Street, Box #11 Kansas City, MO 64106 d. National Credit Union Administration Office of Consumer Financial Protection (OCFP) Division of Consumer Compliance Policy and Outreach 1775 Duke Street Alexandria, VA 22314
3.	Air carriers	Asst. General Counsel for Aviation Enforcement & Proceedings Aviation Consumer Protection Division Department of Transportation 1200 New Jersey Avenue, S.E. Washington, DC 20590
4.	Creditors Subject to the Surface Transportation Board	Office of Proceedings, Surface Transportation Board Department of Transportation 395 E Street, S.W. Washington, DC 20423
5.	Creditors Subject to the Packers and Stockyards Act, 1921	Nearest Packers and Stockyards Administration area supervisor
6.	Small Business Investment Companies	Associate Deputy Administrator for Capital Access United States Small Business Administration 409 Third Street, S.W., Suite 8200 Washington, DC 20416
7.	Brokers and Dealers	Securities and Exchange Commission 100 F Street, N.E. Washington, DC 20549
8.	Federal Land Banks, Federal Land Bank Associations, Federal Intermediate Credit Banks, and Production Credit Associations	Farm Credit Administration 1501 Farm Credit Drive McLean, VA 22102-5090
9.	Retailers, Finance Companies, and All Other Creditors Not Listed Above	Federal Trade CommissionConsumer Response Center 600 Pennsylvania Avenue, N.W.W ashington, DC 20580(877) 382-4357

Applicant Signature *

Clear Signature

TO BE READ AND SIGNED BY THE APPLICANT

_{§391.21(b)(12)}

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. I hereby authorize Service Transfer, Inc. to make such investigations and inquiries of my personal, employment, financial, and/or medical history and other related matters as may be necessary in arriving at an employment decision. (Note: inquiries involving medical history will be made only if and after a conditional offer of employment has been extended.)I hereby release employers, schools, health car providers, and other persons from all liability in responding to inquiries and releasing information in connection with my application.

I understand that information that I provide regarding current and/or previous employers may be used for the purpose of investigating my safety performance history as required by Section 391.23(d) and (e) of the Federal Motor Carrier Safety Regulations. 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 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.

In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I further understand that I will be on a probationary period of 60 days and may be released from work during that period without explanation. I also understand that in accordance with the Federal Motor Carrier Safety Regulations, Section 391.103, I am required to submit to urinalysis testing upon acceptance of employment. A positive test for controlled substances and/or alcohol will medically disqualify me from the operation of a commercial motor vehicle and my employment with this company will be terminated immediately.

Date Submitted *

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