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CSI Freight, LLC

License & Driving Information

No person who operates a commercial motor vehicle shall at any time have more than one driver’s license (49 CFR 383.21). I certify that I do not have more than one motor vehicle license, the information for which is listed below. Include all licenses held for the past 3 years.

DRIVING EXPERIENCE

ACCIDENT RECORD FOR THE PAST 3 YEARS

TRAFFIC CONVICTIONS AND FORFEITURES FOR THE PAST 3 YEARS (OTHER THAN PARKING VIOLATIONS)

CURRENT (MOST RECENT) EMPLOYER

SECOND (MOST RECENT) EMPLOYER 

THIRD (MOST RECENT) EMPLOYER

EDUCATION

Attach clear copies of the following

A copy of the SS card will be taken at the interview

TO BE READ AND ACKNOWLEDGED BY APPLICANT

I authorize you to make investigations (including contacting current and prior employers) into my personal, employment, financial, medical history, and other related matters as may be necessary in arriving at an employment decision. I hereby release employers, schools, health care providers, and other persons from all liability in responding to inquiries 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. I also understand that I am required to abide by all rules and regulations of the Company.

I understand that the information I provide regarding my current and/or prior 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. I understand that I have the right to:

• Review information provided by current/previous employers.
• Have errors in the information corrected by previous employers, and for those previous employers to resend the corrected information to the prospective employer; 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.

Request for Driver’s Safety Performance History Information from DOT Regulated Previous Employer

As a Commercial Motor Vehicle (CMV) Driver, I understand that per, the Federal Motor Carrier Safety Regulations (FMCSRs) Part 391.21, the following information will be requested from all previous employers for which I operated a CMV, subject to the FMCSR Parts 390 and/or 40, 382 & 383, within the past three years, from the date shown below. I also acknowledge that this information will be used in determining my eligibility to be hired, that I have the right to review this information and rebut any errors in these statements from my prior employers, as described in the FMCSR Part 391.23.

hereby authorize this company to release all records of employment, including assessments of my job performance, ability and fitness, including dates of any and all alcohol or drug tests. Those confirmed results and/or my refusal to submit to any alcohol or drug tests and any rehabilitation completion under direction of (SAP/MRO) to each and every company (or their authorized agents) which may request such information in connection with my application for employment with said company. I hereby release this company, and its employees, officers, directors, and agents from any and all liability of any type as a result of providing information to the above-mentioned person and/or company.

Driver Record Request

Company Name: CSI Freight LLC

In order to meet the Federal Motor Carrier Safety Regulations, 49 CFR 391.23, as a condition of your employment, your company is required to review the driving record of a newly-hired driver and to place the record in the driver qualification file. Under 49 CFR 391.25, your company is also required to review the annual driving record for all existing employees. Under 49 CFR 391.23 and 391.51, your company is required to maintain a driving record on file indicating a CDL driver's medical status within 15 days
of a renewed Medical Certification. Below indicates the types of driving records required to be reviewed:

-Initial Driving Record (3 years back of accidents and moving violations)

-Annual Driving Record (3 years back of accidents and moving violations)

-Medical Certification verification on file with Drivers License office

Acknowledgement below indicates my understanding of the Federal Motor Carrier Regulations requirements and that my company will be requesting a driving record. I further understand that failure to sign may result in termination of employment.

COMMERCIAL MOTOR VEHICLE DRIVER’S CERTIFICATION WITH DRIVER LICENSE REQUIREMENTS

General Consent for Limited Queries of Federal Motor Carrier Safety Administration (FMCSA) Drug and Alcohol Clearinghouse

to conduct a limited query of the FMCSA Commercial Driver’s License Drug and Alcohol Clearinghouse to determine whether drug or alcohol violation information about me exists in the Clearinghouse. By signing this consent, I am also giving CSI Freight LLC consent to run multiple limited queries throughout the duration of my employment with CSI Freight LLC.

I understand that if the limited query conducted by CSI Freight LLC indicates that drug or alcohol violation information about me exists in the Clearinghouse, FMCSA will not disclose that information to CSI Freight LLC without first obtaining additional specific consent from me.

I further understand that if I refuse to provide consent for CSI Freight LLC to conduct a limited query of the Clearinghouse, CSI Freight LLC must prohibit me from performing safety-sensitive functions, including driving a commercial motor vehicle, as required by
FMCSA’s drug and alcohol program regulations.

Receipt of Written Policy and Educational Materials for Alcohol and Controlled Substances