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If yes, please indicate hire and termination date:   

I understand that, as required by the Federal Motor Carrier Safety Regulations and company policy, all drivers must submit to alcohol and controlled substance testing as a condition of employment. I also understand that any offer of employment will be contingent upon the results of an alcohol and controlled substance test.

Therefore, I agree to submit to the following alcohol and controlled substance tests in accordance and as defined by the Federal Motor Carrier Safety Regulation and this company’s policies:

• Pre-Employment, to determine employment eligibility
• Random
• Reasonable Suspicion
• Post Accident

I certify that I have read, understand, and agree to abide by the condition of this consent and release form.

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 Par: 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; it does not release any violation or testing information. Before a motor carrier may request a full or 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 full or "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

JP Express Service, 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 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.

INSTRUCTIONS: The Operator-Applicant must complete this consent form to authorize the Prospective Employer, named below, to request the operator-applicant's records from the PSP system. The Prospective Employer must provide the documentation described in the second paragraph, in the event this paragraph applies. The FMCSA established the system of records under the Privacy Act of 1974 (5 U.S.C. 552a) for its Pre-Employment Screening Program (PSP), as required by 49 U.S.C.31150.

Prospective motor carrier employer JP Express Service Inc. intends to request your crash data for the previous five (5) years and your inspection history for the previous three (3) years from the Federal Motor Carrier Safety Administration's (FMCSA) Pre- Employment Screening Program (PSP). This data will be extracted from FMCSA's Motor Carrier Management Information System (MCMIS). This data will only be used for pre-emplo yment screening purposes.

Crash and inspection records in the PSP database will be retrieved by using the operator-applicant's last name, license number, and license state. Additional operator-applicant information, such as date of birth and first name, will be used to confirm the accuracy of the search.

If the Prospective Employer named above uses any information it obtains from the PSP 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 on the PSP report, the Prospective Employer will notify you that the action has been taken and that the PSP report was the reason for the action.

I understand that I, as an operator-applicant, can seek to correct inaccurate information in the PSP via the DataQs system currently maintained by the FMCSA. Only FMCSA, and not FMCSA's contractor, is authorized to receive proposed corrections to database information and determine if the information should be corrected.

In exchange for the Prospective Employer's consideration of my employment application, I agree not to file or pursue any complaints, claims, or legal actions of any kind against any organization or individual that provides the information described above to the Prospective Employer named above or to its agents. I also agree not to file or pursue any complaints, claims or legal actions against Prospective Employer or any of its employees, representatives, or agents arising out of their efforts to obtain this information.

I hereby authorize the Prospective Employer named above and its employees, agents, and affiliates to obtain the information described above.

This request is made by the driver/applicant in compliance with the Department of Transportation regulations.

§391.23(i)(2)

Drivers who have previous Department of Transportation regulated employment history in the preceding three years, and wish to review previous employer-provided investigative information must submit a written request to the prospective employer, which may be done at any time, including when applying, or as late as thirty (30) days after being employed or being notified of denial of employment. The prospective employer must provide this information to the applicant within five (5} business days of receiving the written request. If the prospective employer has not yet received the requested information from the previous employer(s), then the five-business-days deadline will begin when the prospective employer receives the requested safetyperformance history information. If the driver has not arranged to pick up or receive the requested records within thirty (30) days of the prospective employer making them available, the prospective motor carrier may consider the driver to have waived his/her request to review the records.

COMPLETED BY THE DRIVER/APPLICANT

TO: Prospective Employer:

JP Express Service, Inc.
131 Hoffman Lane
Islandia, New York 11749
Phone Number: 800-331-8065

FROM:

 

I am submitting this written request to obtain copies of my Department of Transportation Safety Performance History for the preceding three years. I understand, for records requested from a prospective employer, that I must arrange to pick up or receive the requested records within thirty (30) days of the records being made available or I have waived my request to review the records,

COMPLETED BY THE PROSPECTIVE EMPLOYER

The information must be provided to the applicant within five (5) business days of receiving the written request. If the prospective employer has not yet received the requested information form the previous employer(s), then the five-business-days deadline will begin when the prospective employer receives the requested safety performance history information.

Information supplied to: JP Express Service, Inc. 131 Hoffman Lane, Islandia, NY 11749

Telephone 800-331-8065