For California applicants: Please do not disclose misdemeanor convictions for marijuana-related offenses that are more than 2 years old, convictions that have been expunged, sealed, or statutorily eradicated; misdemeanor convictions for which probation has been successfully completed or discharged, and the case has been judicially dismissed; or Any referrals to a diversion program.
Have you ever been convicted of or are charges currently pending for any of the following:
I authorize you to make such investigations and inquiries of my personal, employment, financial or 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 and/or drug & alcohol testing information in accordance with FMCSA regulations.
By signing below, I certify that; (i) all information provided herein is complete and accurate; (ii) I have read and fully understand Part I, DISCLOSER AND AUTHORIZATION FOR RELEASE OF INFORMATION FOR EMPLOYMENT PURPOSES – 49 CFR PART 391.23 DOT DRUG & ALCOHOL TESTING; and Part II – CONSUMER REPORT AND INVESTIGATIVE CONSUMER REPORT DISCLOSURE (FOR EMPLOYMENT PURPOSES); (iii) prior to signing, I was given an opportunity to ask questions and to have those questions answered to my satisfaction; (iv) I execute this authorization voluntarily and with the knowledge that the information obtained pursuant to this authorization could affect my eligibility for employment, promotion, retention, or other lawful purpose; (v) I understand I may review this document with legal counsel prior to signing; (vi) I authorize USIS and any person or entity contacted by USIS to furnish the above-mentioned information; and (vii) facsimile or photographic copies of the authorization are as valid as an original.
I hereby authorize Prospective Employer and its employees to obtain a PSP report of my crash and inspection history-CSA.
The Applicant has released all liability of you and your company and all information will be held in strict confidence.