Martin Employment Application

Martin Application
Dear Applicant: Per FMCSR 391.21(d) Before an application is submitted, the motor carrier shall inform the applicant that the information he/she provides for the employment history may be used, and the applicant’s prior employers may be contacted, for the purpose of investigating the applicant’s safety performance history information. The prospective employer must also notify the driver in writing of his/her due process rights as specified in §391.23(l) regarding information received as a result of these investigations. You, the applicant, have the following rights: (l) The right to review information provided by previous employers; (ll) The right to have errors in the information corrected by the previous employer and for the previous employer to re-send the corrected information to the prospective employer; (lll) The right to have a rebuttal statement attached to the alleged erroneous information, if the previous employer and the driver cannot agree on the accuracy of the information.
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Signature *

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Section 3 - Driver Experience & Qualifications
Licenses: List all licenses held in last 3 years
Do you currently hold more than one valid license?

Yes No
Have you ever been denied a license, permit or privilege to operate a motor vehicle?

Yes No
Has any license, permit or privilege ever been suspended or removed?

Yes No
Have you ever been disqualified for violations of the Federal Moter Carrier Safety Regs?

Yes No
If answered Yes to any above, give details.
Experience
List States operated in during last 5 years:
List safe driving awards held and who presented by:
Accident review for the past 3 years
Motor Vehicle Laws and Ordinances for the past 3 years other than parking violations
Applicant: Read and sign before submitting this application.
I understand that the information in this application will be used and that prior
employers will be contacted for the purposes of investigating my safety
performance history information as required by §391.23 (d) (e). 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.
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Month Day Year
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Signature *

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Driver's Certification and Annual Review
The Federal Motor Carrier Safety Regulations requires drivers to furnish a list
of motor vehicle traffic law violations at least once every 12 months.
The regulation further requires motor carriers to review the driving records
at least once every 12 months.
Driver Name
Date

Month Day Year
Date
I certify that the following is a true and complete list of traffic violations (other than parking violations) for which I have been convicted of or forfeited bond or collateral during the last 12 months. *

I certify I have not been convicted of or forfeited bond or collateral on account of any violations to be listed during the past 12 months. I have received violations to my driving record in the past 12 months and they include:
Accident review for the past 3 years
Date *

Month Day Year
Date
Driver Signature *

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General Consent forLimited Queries of the Federal MotorCarrier SafetyAdministration (FMCSA) Drug and AlcoholClearinghouse
I, ________{driverName}_____________________, hereby provide consent to Martin’s Bulk Milk Service, Inc to conduct a limited query of the FMCSA Commercial Driver’s License Drug and Alcohol Clearinghouse (Clearinghouse) to determine whether drug or alcohol violation information about me exists in the Clearinghouse. This consent is valid for unlimited number of limited queries and never expires for the duration of your employment.

I understand that if the limited query conducted by Martin’s Bulk Milk Service, Inc. indicates that drug or alcohol violation information about me exists in the Clearinghouse, FMCSA will not disclose that information to Martin’s Bulk Milk Service, Inc. without first obtaining additional specific consent from me. (Which requires me to create an account with the clearinghouse and grant permission for a full query to be conducted.)

I further understand that if I refuse to provide consent for Martin’s Bulk Milk Service, Inc. to conduct a limited query of the Clearinghouse, Martin’s Bulk Milk Service, Inc. must prohibit me from performing safety-sensitive functions, including driving a commercial motor vehicle, as required by FMCSA’s drug and alcohol program regulations. We will also report on the clearinghouse that you refused to provide consent.
Driver Name *
Date *

Month Day Year
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Driver Signature *

Clear
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 Martin’s Bulk Milk Service, Inc. (“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 if 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 suppling 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 Regulation (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 Martin’s Bulk Milk Service, Inc (“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 suppling 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.
Date *

Month Day Year
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Driver Signature *

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Driver Name *
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.

LAST UPDATED 12/22/2015

Martin Application

Section 2 - Employment Information

Section 3 - Driver Experience & Qualifications

Driver's Certification and Annual Review

General Consent forLimited Queries of the Federal MotorCarrier SafetyAdministration (FMCSA) Drug and AlcoholClearinghouse