3. TO BE READ AND AUTHORIZED BY APPLICANT *Required Fields
INVESTIGATIVE CONSUMER REPORT DISCLOSURE
Disclosure and Authorization Statement
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 entities to Summit Express Inc/Diamond Delivery Service LLC (the Company). These reports (collectively, “Reports”) may relate to information concerning my: previous employment, (including employers, dates of employment, salary information, reasons for termination, etc.), academic history, verification of references and verification of other information supplied by me, professional credentials, drug/alcohol use in violation of law and/or company policy, driving record, accident history, workers’ compensation claims, credit history, creditworthiness, credit capacity, bankruptcy filings, criminal history records and information about my character, general reputation, personal characteristics and mode of living (collectively, “Information”). Information may be obtained from government agencies, educational institutions, contractual third parties, personal references, personal interviews and other information sources (collectively, “Suppliers”).
I authorize HireRight (third party entity contracted with the Company), 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 Company to obtain or assemble consumer reports and/or investigative consumer reports (collectively, “Reports”) related to any of the above information. Furthermore, Customers of the Company may require investigative or consumer reports which apply to my background. These reports would apply to my assignment 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 if the Company hires me, my consent will apply, and the Company may obtain 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.
Upon providing proper identification and subject to applicable legal requirements and restrictions, I have the right to request the nature and substance of all Information in the Company’s files pertaining to me, as well as information including, but not limited to: (i) whether any Reports have been provided by the Company to other parties; (ii) identification of any Suppliers utilized by the Company in compiling such Reports; and (iii) identification of any recipients of Reports furnished by the Company within certain statutorily-prescribed time periods preceding my request. (HireRight may be contacted by mail at P.O. Box 33181, Tulsa, Oklahoma, 74153, or by phone at (800) 381-0645.)
I understand that I have the right to receive, upon written request within a reasonable period of time, (not to exceed 30 days) a complete and accurate disclosure of the nature and scope of the investigation requested. I have the right to make a request to HireRight, upon proper identification, to request the nature and substance of all information in its files on me at the time of my request, including the sources of information on me that HireRight has previously furnished with the two-year period preceding my request.
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-sent 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 employers 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. Other reports required by the Federal Motor Carrier Safety Regulations are Sections 391.25 and 382.413. Request to review previous employer information must be in writing. A release form for employment records can be required by calling the Company at 800-555-7832 or mail to 2312 Northyard Court, Fort Wayne, Indiana, 46818.
By my signature below, I certify the information I provided on my 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 understand that any false, misleading, or misrepresentation of information given shall be considered an act of dishonesty and grounds for refusing a contract hire opportunity or terminating lease agreement. 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.
I agree and understand that the Company may investigate my background, including my past employment, education, and driving record. I further agree to indemnify the Company against any liability that may result from making such an investigation.
I understand that if offered a contract hire opportunity, I will be required to take a physical examination if applicable and a pre-employment drug screen and authorize the company chosen physician to release any information which may be necessary to determine my ability to perform the duties of the job.
I authorize the Company to contact any organization or individual that I have listed on my employment record, or mentioned in job interviews, and obtain from them any relevant information about my job qualifications, including my experience, skills, and abilities. I understand that I am consenting to the release of safety performance information including crash date from the previous five (5) years and inspection history from the previous three (3) years, as well as any reference-related information about me held or known by my former employers, supervisors, and co-workers.
Residents of California, Minnesota, Oklahoma, Maine, Massachusetts, or Washington, or individuals with jobs located in these states, may request a fee copy of consumer or investigative consumer reports pertaining to them.
DOT Drug and Alcohol History Release Authorization
By my signature below, I authorize, per 49 CFR Part 40, the release of information from any DOT regulated drug and alcohol testing records by the carriers (company/school) listed below to the Company for the sole purpose of transmitting such records to the listed employer. I authorize release of the following information concerning DOT drug and alcohol testing violations including pre-employment tests during the past three (3) years: (i) alcohol test with a result of 0.04 or higher; (ii) verified positive drug tests; (iii) refusals to be tested (including verified adulterated or substituted results); (vi) other violations of DOT drug and alcohol testing regulations; (v) information obtained from previous employers of a drug and alcohol violation(s); and (vi) documents, if any, of completion of a return to duty process following a rule violation.
The information that I have authorized the Company to review involves tests required by DOT. If any carrier (company/school) listed below furnishes the Company with information concerning items (i) through (vi) above, I also authorize the carrier (company/school) to release and furnish the dates of my negative drug and/or alcohol tests and/or tests with results below 0.04 during the three (3) year period and the name and phone number of any substance abuse professional who evaluated me during the past three (3) years.
I also authorize the release of all information concerning my referral to a Substance Abuse Professional (SAP) including all records pertaining to my evaluation and treatment (if required by SAP). I authorize this release by whatever means is most expedient and agree to hold harmless any person or company for whom I worked or with whom I applied, as well as their employees, agents, or representatives, from all liability or damage that may arise from the release of the information specifically authorized here.