TO BE READ AND SIGNED BY APPLICANT

I authorize you to make such investigations and inquire of my personal, employment, financial or medical history and 

other related matters as may be necessary in arriving at a contract decision. (Generally, inquiries regarding medical 

history will be made only if and after a conditional offer of employment has been extended.) I hereby release employers, 

schools, health care providers and other persons from all liability in responding to inquires and releasing information in 

connection with my application. 

In the event of employment, I understand that false or misleading information given in my application or interview(s) may 

result in discharge or contract termination. I understand, also that I am required to abide by all rules and regulations of the Company. If I 

terminate my contract by my own choice within 90 days, I agree to be responsible for the cost of the Drug Test and 

other associated fees involved in my background check. 

I understand that information I provide regarding current and/or previous employers may be used, and those employer(s) 

will be contacted, for the purpose of investigating my safety performance history as required by 49 CFR 391.23(d) and 

(e). 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 re-send the corrected information to the prospective carrier; 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
I also understand that if I terminate my contract within the first 90 days I will be responsible for $100 in pre-placement testing and associated costs.