Gholia Bros Trucking

Company

Address

City

State

Zip

APPLICANT INFORMATION

Name

Position Applying For

Phone

Emergency Phone

Age

Date of Birth

Physical Exam Expiration Date

Current & Previous Three Years Addresses

Previous Employment with This Company

Have You Worked for This Company Before?

Yes

Reason for Leaving

If Yes, Give Dates: From

MILITARY RECORD

Branch

Dates: From

Attach File

EDUCATION HISTORY

EMPLOYMENT HISTORY

Record of all employment for the past three (3) years, including an unemployment or self-employment. Give a record of all commercial driving experience for the past ten (10) years

Mo/Yr From

Mo/Yr To

Position Held

Reason for Leaving

Present or Last Employer Name / Unemployed

Employer Address

Employer Company Phone

Were you subject to the FMCSRs while employed here?

Yes

Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40?

Yes

DRIVING EXPERIENCE

Class of Equipment

Mo/Yr From

Mo/Yr To

Approximate Number of Miles

List states operated in, for the last five (5) years

List special courses/training (PTD/DDC, HAZMAT)

List any Safe Driving Awards you hold and from whom

Accident Record (Last 3 Years)

Date of Accident

Location

Nature of Accident

# of Fatalities

# of Injuries

Traffic Convictions and Forfeitures (Last 3 Years)

Date

Location

Charge

Driver's License (Last 3 Years)

State

License Number

Endorsements

Expiration Date

Penalties

Eligibility & Legal Questions

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

Yes

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

Yes

Is there any reason you might be unable to perform the functions of the job for which you have applied (as in the job description)?

Yes

Have you ever been convicted of a felony?

Yes

If the answer to any of the questions above is "Yes", please provide details:

To Be Read and Signed by Applicant:

It is agreed and understood that any misrepresentation given on this application shall be considered an act of dishonesty.

It is agreed and understood that the motor carrier or his agents may investigate the applicant's background to obtain any and all information of concern to applicant’s record, whether same is of record or not, and applicant releases employers and person named herein from all liability for any damages on account of his furnishing such information.

It is also agreed and understood that under the Fair Credit Reporting Act, Public Law 91-508, I have been told that this investigation may include an investigating Consumer Report, including information regarding my character, general reputation, personal characteristics, and mode of living.

I agree to furnish such additional information and complete such examinations as may be required to complete my application file.

It is agreed and understood that this Application in no way obligates the motor carrier to employ or hire the applicant.

It is agreed and understood that if qualified and hired, I may be on a probationary period during which time I may be disqualified without recourse.

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.

Applicant Signature:

Date:

Gholia Bros. Trucking, LLC

(253)639-2630 OFFICE PHONE
(253)639-9716 OFFICE FAX
PO Box 9131, Covington, WA 98042

PAST EMPLOYMENT VERIFICATION

I hereby authorize you to release the following information to Gholia Bros. Trucking LLC. for purposes of investigations as required by section 391.23 and 382.413 of the Federal Motor Carrier Safety Regulations. You are released from any and all liability that may result from furnishing such information.

I hereby authorize my previous employer to release and forward all information regarding my duties, character, conduct, accident history, and any Alcohol and Controlled Substances Testing/Training records while in your employ.

SS#

Print Full Name

Date

Applicant Signature:

Gholia Bros. Trucking, LLC

Release of Information Authorization

By signing this Release of Information form, you hereby authorize, without liability, Gholia Bros. Trucking, LLC. (herein referred to “GHOLIA BROS.”) to contact any person or organization whose name you have given as reference or by whom you have been previously employed. You hereby authorize your previous employer to release and forward all information regarding your duties, character, conduct, accident history and any Alcohol and Controlled Substances Testing /Training records while in you were employed. You hereby authorize GHOLIA BROS. to obtain and review your credit report/background. Your credit report/background will be obtained from a credit reporting agency chosen by GHOLIA BROS. You understand and agree that GHOLIA BROS. intends to use the credit report for the purpose of evaluating your employment ability. You hereby release all persons and organizations from any claims for damages of any kind which may occur to you by reasons for furnishing such information. You acknowledge that you may be required and agree to submit to drug and alcohol testing as part of the employment process, and authorize release of your results to GHOLIA BROS., and agree that any offer will be contingent on the results. You hereby authorize all past employers to release the following information to GHOLIA BROS. for purposes of investigations as required by Section 391.23 and 382.413 of the Federal Motor Carrier Safety Regulations. These employers are released from any and all liability that may result from furnishing such information. You authorize any law enforcement agency or court of record to furnish GHOLIA BROS. information concerning Motor Vehicle Record, CSA scores with the use of the PSP, or any felony or misdemeanor of which you have been convicted. You acknowledge and agree that you will familiarize yourself with and abide by all present and subsequently issued rules, policies, or procedures of GHOLIA BROS.

Print Full Name

SS#

Date

Date Of Birth

Applicant Signature:

THE BELOW DISCLOSURE AND AUTHORIZATION LANGUAGE IS FOR MANDATORY USE BY ALL ACCOUNT HOLDERS

IMPORTANT DISCLOSURE

REGARDING BACKGROUND REPORTS FROM THE PSP Online Service

In connection with your application for employment with Gholia Bros. Trucking, LLC (“Prospective Employer”), Prospective Employer, its employees, agents or contractors may obtain one or more reports regarding your driving, and safety inspection history from the Federal Motor Carrier Safety Administration (FMCSA).

When the application for employment is submitted in person, if the Prospective Employer uses any information it obtains from FMCSA in a decision to not hire you or to make any other adverse employment decision regarding you, the Prospective Employer will provide you with a copy of the report upon which its decision was based and a written summary of your rights under the Fair Credit Reporting Act before taking any final adverse action. If any final adverse action is taken against you based upon your driving history or safety report, the Prospective Employer will notify you that the action has been taken and that the action was based in part or in whole on this report.

When the application for employment is submitted by mail, telephone, computer, or other similar means, if the Prospective Employer uses any information it obtains from FMCSA in a decision to not hire you or to make any other adverse employment decision regarding you, the Prospective Employer must provide you within three business days of taking adverse action oral, written or electronic notification: that adverse action has been taken based in whole or in part on information obtained from FMCSA; the name, address, and 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 your 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 Gholia Bros. Trucking, 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, 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.

Print Full Name

Date

Signature

NOTICE: This form is made available to monthly account holders by NIC on behalf of the U.S. Department of Transportation, Federal Motor Carrier Safety Administration (FMCSA). Account holders are required by federal law to obtain an Applicant’s written or electronic consent prior to accessing the Applicant’s PSP report. Further, account holders are required by FMCSA to use the language contained in this Disclosure and Authorization form to obtain an Applicant’s consent. The language must be used in whole, exactly as provided. Further, the language on this form must exist as one stand-alone document. The language may NOT be included with other consent forms or any other language.

NOTICE: The prospective employment concept referenced in this form contemplates the definition of “employee” contained at 49 C.F.R. 383.5.

LAST UPDATED 2/11/2016

APPLICANT INFORMATION

Previous Employment with This Company

MILITARY RECORD

EDUCATION HISTORY

EMPLOYMENT HISTORY

DRIVING EXPERIENCE

Accident Record (Last 3 Years)

Traffic Convictions and Forfeitures (Last 3 Years)

Driver's License (Last 3 Years)

Eligibility & Legal Questions

To Be Read and Signed by Applicant:

Gholia Bros. Trucking, LLC

PAST EMPLOYMENT VERIFICATION

Gholia Bros. Trucking, LLC

Release of Information Authorization

IMPORTANT DISCLOSURE

REGARDING BACKGROUND REPORTS FROM THE PSP Online Service

AUTHORIZATION

Contact Info

Opening Time

Mon - Friday:

Sat - Sunday:

On-Text:

Our Services

Gholia Bros Trucking