3655 S Maize Rd. Wichita, KS 67215 - US Road Freight Express · U.S. Road Freight Express, Inc. Attention: Safety Department/ Human Resources Dept. Telephone: 316-942-9944. Street:

Revised 2/24/12 Page 1

(Driver Application for Employment)

3655 S Maize Rd. Wichita, KS 67215

In compliance with federal and state equal employment opportunity laws, qualified applicants are considered for all positions without regard to race, color, religion, age, sex, national origin, marital status or non-job related disabilities. Substance and Alcohol Testing is required of application driver if operating CDL equipment (GVWR 26,001 # or greater).

___________________________ ________________________________________ Date Telephone Number with Area Code

Last Name First Name Middle Initial

Complete Social Security Number Date of Birth

____________________________________________________________________________________________________________ Address – Number & Street City, State Zip Code Length of Time at this Residence

Note: If you have resided at the above address for less than three years, please list all addresses of residence in last three years: (including number & street, city, state, zip code, and length)

____________________________________________________________________________________________________________

_______________________________________ ___________ _____________________________________ Driver’s License Number State Expiration Date

Y N

Are you 21 years of age or older?

Can you provide proof of age?

Have you ever worked for this company before?

Are you currently employed?

If you are currently employed, may we contact your current employer?

If you are not currently employed, what was the last day you worked for your last employer? ____________________________

Check Yes or No to the following three questions. Y N

Have you ever been denied a license, permit or privilege to operate a motor vehicle?

Have you ever had a license, permit or privilege revoked or suspended?

Have you ever been convicted of a felony?

If any of the above questions are answered YES, please attach a statement with details


Accident Record List all traffic accidents in which you were involved, regardless of fault, for the last three years

Date of Accident

What was the nature of the Accident Were there

Fatalities

DOT Record-

able

Were their

Injuries

Prevent-able

Charge-able

Traffic Convictions and Forfeitures for the Past Three Years

Date Location Charge Penalty

Experience – Qualifications List all drivers’ licenses issued to you in the past five years

State License Number Type of Equipment Dates Approximate

Number of Miles

List the states you have operated a Commercial Motor Vehicle in during the past five years: _________________________________

I certify that I have read and understand all of this employment application. It is agreed and understood that the employer

or his agents may investigate my background to ascertain any and all information of concern per FMCSA Regulations

Subpart C & Subpart F. I release all employers and other persons named herein, from all liability for damages by

furnishing such information. I understand that as an applicant for a position with this company, I may be asked to

demonstrate that I am capable of performing tasks, which are pertinent to the job. I also understand that if offered a job, it

may be conditioned on the results of a physical examination and drug test. If hired, I agree to abide by all the rules and

policies of the employer and those agencies which regulate this employer.

This certifies that I completed this application, and all entries of information on it are true and complete to the best of my

knowledge.

_____________________________________ _________________________________________________________ Date Applicant’s Signature


Employment History All driver applicants, to drive in interstate commerce, must provide the following information on all employers during the preceding three years. Applicants to drive a

commercial motor vehicle in intrastate and interstate commerce shall also provide an additional seven years information on those employers for whom the applicant operated

such vehicles. Failure to list all previous employers for the preceding ten years, applicant will not be considered for employment. List with your most recent employment shown

first. Failing to list telephone numbers for those employers will delay the processing.

List your most recent employer first then work backwards showing all employers for past 3 years (Non-CDL) or 10 years (CDL)

Employer Name

Was your previous employer subject to FMCSA?

Did you ever test for your previous employer under the guidelines of the FMCSA?

Address, City & State Telephone Number Dates of Employment

Position Reason for Leaving

U.S. Road Freight Express, Inc.

Yes/ No Yes/ No 3655 S Maize Rd. Wichita, KS 67215 316.942.9944

_ To current

This certifies that this application was completed by me, and that all entries on it are true and complete to the best of my knowledge. I authorize you to make such investigations and inquiries per FMCSA Regulations stated in Subpart C-Background & Character and Subpart F Files & Records (391) necessary in arriving at an employment 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, 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 the employment, I understand that false or misleading information given in my application or interview's) may result in discharge/termination. I understand, also that I am required to abide by all rules and regulations of the company.

_____________________________________ _______________________________________________________________________________ Date Applicant’s Signature


Employer Name

Was your previous employer subject to FMCSA?

Did you ever test for your previous employer under the guidelines of the FMCSA?

Address, City & State Telephone Number Dates of Employment

Position Reason for Leaving


Motor Vehicle Records (Drivers License and Vehicle Title/Registration Records)

3rd Party Consent (Please print or type)

I hereby certify that my name is __________________________________________________________________________________ (First Name) (Middle Initial) (Last Name)

I further certify that my date of birth is: ________________ My Drivers License Number is: ________________________________

My Current address is:__________________________________________________________________________________________ (Street) (Apartment/Unit) (City) (State) (ZIP)

and my telephone number is: _______________________________________________________________

I herby authorize: U.S. Road Freight Express, Inc. / Corporate Safety Compliance, Inc.

to obtain my driver’s license record and/or vehicle registration information including my personal information on those records.

_______________________________________ _________________________________________________________ (Date) (Signature)


U.S. DEPARTMENT OF TRANSPORTATION

MOTOR CARRIER SAFETY PROGRAM

INQUIRY TO STATE AGENCY FOR

DRIVER’S RECORD

391.23

(Drivers Name)

(Driver’s Operator License Number)

(Driver’s Social Security Number)

The above listed individual has made application with us for employment as a driver. Applicant has indicated that the

above numbered operator’s license or permit has been issued by your State to applicant and that it is in good standing.

In accordance with Section 391.23(a)(1) and (b) of the Federal Motor Carrier Safety Regulations, we are required to make

inquiry into the driving record during the preceding 3 years of every State in which the applicant-driver has held a motor vehicle

operator’s license or permit during those three years.

Therefore, please certify to us what the individual’s driving record is for the preceding 3 years, or certify that no record

exists if that be the case.

In the event that this inquiry does not satisfy your requirements for making such inquiries, please send us such forms of

yours as are necessary for us to complete our inquiry into the driving record of this individual.

Respectfully Yours,

U.S. Road Freight Express, Inc../ CSC, Inc.

Signature of individual making inquiry

U.S. Road Freight Express, Inc. / Corporate Safety Compliance, Inc.

Name of person making inquiry

Safety Consultant

Title of person making inquiry

U.S Road Freight Express, Inc.

Motor Carrier Name

3655 S. Maize Road Wichita, KS 67215

Street City State Zip


MOTOR VEHICLE DRIVER’S CERTIFICATE OF VIOLATIONS

AND ANNUAL REVIEW OF DRIVING RECORD

MOTOR CARRIER INSTRUCTIONS: Each motor carrier shall at least once every twelve months, require each driver it employs to prepare and furnish it with a list of all violations of motor vehicle traffic laws and ordinances (other than violations involving only parking) of which the driver has been convicted, or on account of which he/she has forfeited bond or collateral during the preceding twelve months (Section 391.27). Drivers who have provided information required by section 383.31 need not repeat that information on this form. DRIVER REQUIREMENTS: Each driver shall furnish the list as required by the motor carrier above. If the driver has not been convicted of, or forfeited bond or collateral on account of any violation which must be listed, he/she shall so certify (section 391.27).

COMPLETED BY DRIVER – CERTIFICATION OF VIOLATIONS

Name of Driver: (Print) DOB

Social Security Number: Date of Employment:

Home Terminal (City & State):

Driver’s License Number: State: Expiration Date:

I certify that the following is a true and complete list of traffic violations required to be listed (other than those I have provided under Part 383) for which I have been convicted or forfeited bond or collateral during the past one year. (If you have had no violations, please state so below.) Date Offense Location Type of Vehicle Operated

____________ _______________________________________________________ _____________ _____________________

____________ _______________________________________________________ _____________ _____________________

Check this box if you have had no traffic violations in the past one year.

If you have had more than two violations in the past one year – please give the information required above on the reverse. If no violations are listed above, I certify that I have not been convicted or forfeited bond or collateral on account of any violation (other than those I have provided under part 383) required to be listed during the past twelve months.

Date of Certification: Drivers Signature: (Today’s Date)

COMPLETED BY MOTOR CARRIER – ANNUAL REVIEW OF DRIVING RECORD

MOTOR CARRIER INSTRUCTIONS: Review the Certification of Violations listed above and other information described in Section 391.25 of the Federal Motor Carrier Safety Regulations. Complete the information below.

I hereby reviewed the driving record of the above named driver in accordance with Section 391.25 and find that he/she (check one) ________ Meets the Minimum requirements for safe driving ________ Is disqualified to drive a motor vehicle pursuant to section 391.25 ________ Does not adequately meet satisfactory safe driving performance

Action taken with driver:________________________________________________________________________________________

____________________________________________________________________________________________________________

Reviewed By: __________________________________________________________ ________________________________ Signature Date

________________________________________________ ________________________________ Printed Name Title

U.S. Road Freight Express, Inc. 3655 S. Maize Road- Wichita, KS 67215

Motor Carrier Name Motor Carrier Address Maintain this document in the Driver’s Qualification file. This document may be purged after three years from date of execution.

Revised 2/24/12 Page

I, (Print Name) ____________________________________________________________________ First Middle Initial Last

________________________

Social Security N umber

_________________________ Date of Birth

Hereby Authorize: _________________________________________________________________

Previous Employer: ________________________________________________________________ _________________________ Email Address

Street: _________________________________________________________________________ _________________________ Telephone Number

City, State, Zip: ___________________________________________________________________ _________________________ Fax Number

To release and forward the information requested by section 3 of this document concerning my Alcohol and Controlled Substances testing records within the previous 3 years.

To: Prospective Employer: U.S. Road Freight Express, Inc.

Attention: Safety Department/ Human Resources Dept. Telephone: 316-942-9944

Street: 3655 S. Maize Road

City, State, Zip: Wichita, KS 67215

In compliance with 40.25(g) and 391.23(h), release of this information must be made in a written form that ensures confidentiality, such as fax, email, or letter.

Prospective employer’s fax number: ______________________________________________________________________________

Prospective employer’s email address: ____________________________________________________________________________

____________________________________ _________________________________________________________________ Date Applicant’s Signature

This information is being requested in compliance with 40.25(g) and 391.23

CFR 391.23(4) Investigation and Inquiries – Exception For drivers with no previous employment experience working for a DOT regulated employer during the preceding three years, documentation that no investigation was possible must be placed in the driver history investigation file, after October 29, 2004 within required 30 days of the date the drivers employment begins.

If employee has been with U.S. Road Freight Express, Inc. for 3 years or longer from the date of completing this application, please check this box and proceed to page 12.

Part 1: TO BE COMPLETED BY PROSPECTIVE EMPLOYEE

Revised 2/24/12 Page

Part 2: TO BE COMPLETED BY PREVIOUS EMPLOYER

Accident History

The applicant named was employed by us. Yes____ No____

The applicant was employed as a: ______________________________ From: (M/Y) To: (M/Y)

1. Did he/she driver a motor vehicle for you? Yes____ No____ If yes, what type: Straight Truck____ Tractor-Semitrailer____ Bus____ Cargo Tank____ Doubles/Triples____ Other (specify) ________________________

2. Reason for leaving your employ: Discharged____ Resignation____ Lay off____ Military Duty____

If there is no safety performance history to report, check here ____, sign below and return.

ACCIDENTS: Complete the following for any accidents included on your accident register (390.15(b)) that involved the applicant in the 3 years prior to the application date show or check here ____ if there is no accident register for this driver.

Date Location # Of Injuries # Of Fatalities Hazmat Spill (Y/N)

1. __________ ______________________ __________ __________ __________

2. __________ ______________________ __________ __________ __________

3. __________ ______________________ __________ __________ __________

Please provide information concerning any other accidents involving the applicant that were reported to government agencies or insurers, or retained under internal company policies.

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

Signature: _________________________________________________

Title: ________________________________ Date: _______________


Part 3: TO BE COMPLETED BY PREVIOUS EMPLOYER

If the driver was not subject to Department of Transportation testing requirements while employed by this employer check here fill in the dates of employment from __________ to __________, complete bottom of Part 3, sign, and return.

Driver was subject to Department of Transportation testing requirements from __________ to __________.

1. Has this person had an alcohol test with the result of 0.04 or higher alcohol concentration? Yes____ No____

2. Has this person tested positive for adulterated specimen or substituted a test specimen for controlled substances?Yes____ No____

3. Has this person refused to submit to a post-accident, random, reasonable suspicion, or follow-up alcohol or controlledsubstance test? Yes____ No____

4. Has this person committed other violations of Subpart B of Part 382 or Part 40? Yes____ No____

5. If this person has violated a DOT drug and alcohol regulation, did this person complete a SAP-prescribed rehabilitationprogram in your employ, including return-to-duty and follow up tests? Yes____ No____ If yes, please senddocumentation back with this form.

6. For a driver who successfully completed a SAP’s rehabilitation referral and remained in your employ, did this driversubsequently have an alcohol test result of 0.04 or greater, a verified positive drug test, or refused to be tested?Yes____ No____

In answering these questions, include any required DOT drug or alcohol testing information obtained from previous employers in the previous 3 years prior to the application date shown on page 1.

Name: ______________________________________________________________

Company: ___________________________________________________________

Street: ______________________________________________________________

City, State, Zip: _______________________________________________________ Telephone: _____________________________

Part 3 Completed by (Signature): _________________________________________________ Date: __________________________

Part 4a: TO BE COMPLETED BY PROSPECTIVE EMPLOYER

This form was (check one): Faxed to previous employer____ Mailed____ Emailed____ Other____________________________

By:__________________________________________________________ Date:_________________________________________

Part 4b: TO BE COMPLETED BY PROSPECTIVE EMPLOYER Complete below when information is obtained:

Information received from: _____________________________________________________________________________________

Recorded by:_____________________________________ Method: Fax____ Mail____ Email____ Telephone____

Date:_______________________ Other:_________________________________________________________________________


INSTRUCTIONS TO COMPLETE THE SAFETY PERFORMANCE HISTORY RECORDS REQUEST

Page 1 – Part 1: Prospective Employee

Complete the information required in this section

Sign and date

Submit to the Prospective Employer

Page 4a: Prospective Employer

Complete the information

Send to Previous Employer

Part 2: Previous Employer


Sign and Date

Complete Section 3

Part 3: Previous Employer


Sign and Date

Return to Prospective Employer

Part 4b: Prospective Employer

Record receipt of information

Retain the form


CARRIERS DRIVER STATEMENT OF ON-DUTY HOURS

(For Newly-Hired or Intermittent Drivers)

INSTRUCTIONS: Motor carriers when using a driver for the first time shall obtain from the driver a signed statement giving the total on-duty time during the immediately preceding seven days and time at which such driver was last relieved from duty prior to beginning work for such carrier. Rule 395.8(j)(2) Federal Motor Carrier Safety Regulations

NOTE: Hours for any compensated work during the preceding seven days, including work for a non-motor carrier entity, must be recorded on this form.

Driver Name (PRINT): __________________________________________________________________________________________

Social Security Number: ________________________________________________________________________________________

Motor Vehicle Operator’s License Number: ________________________________________________________________________

Type of License: ___________________________________________________________ Issuing State: ______________________

Compensated Work Time (Prior 7 Days)

1 2 3 4 5 6 7

____________________________________ Total Hours

I herby certify that the information given above is correct to the best of my knowledge and belief, and that I was last relieved from work at:

____________________________________________ (AM) (PM) ON ________________________________________ Time Date

Are you currently working for another employer? Yes____ No____

At this time do you intend to work for another person while still employed by this company? Yes____ No____

I hereby certify that the information given is true and I understand that once I become employed with the company, if I begin work for any additional employer(s) for compensation that I must inform this company immediately of such employment activity. (395.2(8) and (9))

_________________________ ________________________________________________________________________ Date Driver’s Signature

_________________________ ________________________________________________________________________ Date Witness Signature


U.S. Road Freight Express, Inc. 3655 S. Maize Road Wichita, KS 67215

Privacy Form

Date: _______________________________

By signing this form you authorize Corporate Safety Compliance, Inc. to obtain any and all information pertaining to the DOT physical. All information will be kept private and confidential and will only be used as record for Federal and State regulations as set forth by FMCSA.

_______________________________________________________ Driver’s Name (PLEASE PRINT)

_______________________________________________________ Driver’s Signature

______________________________________________________ CSC, Inc. Representative


RECORD OF ROAD TEST

Drivers Name:

License Number:

Date of Test:

Check if condition satisfactory. If driver needs training place X in column and give explanation.

Pre-Trip Inspection and Emergency Equipment required by 392.7

Coupling and Uncoupling of combination units; if the equipment he/she may drive includes combination units.

Placing of commercial motor vehicle in operation.

Use of the commercial motor vehicle's controls and emergency equipment.

Operating the commercial motor vehicle in traffic and while passing other vehicles

Turning the commercial motor vehicle.

Braking, and slowing the commercial motor vehicle.

Certification of Road Test Per 391.31

Driver's Name

Social Security #

License Number

State

Type of Power Unit

Type of Trailer

This is to certify that the above-named driver was given a road test under my supervision on (date): __________________________ consisting of approximately _______________ miles of driving.

It is my considered opinion that this driver possesses sufficient driving skills to operate safely the type of commercial motor vehicle listed above.

Signature of examiner Title

U.S Road Freight Express, Inc. 3655 S. Maize Road, Wichita, KS 67215 (Company Name) (Company Address)



TO WHOM IT MAY CONCERN

________________________________________________________________ Driver’s Name

Driver is authorized by U.S. Road Freight Express, Inc. to log meal and coffee break periods in excess of 15 minutes in duration as "OFF

DUTY" time under the following conditions:

1.) The vehicle is safely and legally parked with the engine "OFF" and the cab locked while the driver is away from the

vehicle.

2.) During the stop, and for the duration of the stop, the above named driver is at liberty to pursue activities of his/her

choosing.

There are no record retention requirements for the driver to have written authorization onboard the vehicle in order to log meals and breaks off-duty. The original of this document will be retained in the Driver Qualification file.

This authorization relieves the above named driver of responsibility for the care and custody of the vehicle, its accessories and any cargo it may be carrying, during the qualifying "OFF DUTY" periods.

Every driver is reminded that the relief from duty outlined above is intended solely to provide an opportunity to rest and relax from the rigors associated with the operation of a commercial motor vehicle.

_____________________________ _________________________________________________________________ Date Driver’s Signature

_____________________________ _________________________________________________________________ Date U.S. Road Freight Express, Inc. – Authorizing Signature


MOTOR CARRIER: U.S. Road Freight Express, Inc.

__________________________________________________________________ ____________________________________ Applicant Name Social Security Number

Pre-Employment Controlled Substance Testing and Consent Agreement U.S. Road Freight Express, Inc. (Hereinafter referred to as The Company) in compliance with the USDOT Federal Motor Carrier Safety Regulations, Part 382-Subpart C, is required to administer a prescribed controlled substances test as part of the mandatory pre-employment screen process. No offer of employment may be tendered to you, nor may employment commence until the controlled substances test has been taken and The Company has been advised of the results, which must be NEGATIVE. I agree to submit to the controlled substances testing described above, via the prescribed testing methods, at the site selected by The Company, on the appointed date and time.

I understand that the results of this testing procedure are confidential, and are only for the use of The Company, their Medical Review Officer, and me. I also understand that a POSITIVE result will disqualify me from operation of a Commercial Motor Vehicle for The Company and therefore will exclude me from the position applied for. I have read and understand the conditions imposed by the controlled substances testing requirements and by my signature below, consent to such testing.

DRIVER RECEIPT OF DRUG AND ALCOHOL EDUCATIONAL MATERIALS INSTRUCTIONS: FMCSR Part 382.601 require The Company to provide all company drivers with educational material regarding drug and alcohol use and abuse, and the rules and regulations of the Department of Transportation which may apply to The Companies drivers. This form will document receipt of the required materials.

TO THE DRIVER: The FMCSR require that each driver must sign this form to certify receipt of these materials. The original of this form will be maintained for an indefinite period of time in a file with other company records being maintained pertaining to the mandated drug and alcohol testing program. Drivers may request a copy of this certification.

Driver’s Certification The undersigned herby certifies the receipt of the educational materials, which The Company is required to provide in accordance with 49 CFR Part 382.601. I acknowledge and agree that I am responsible for reading, understanding, and complying with all company policies and Depart of Transportation regulations regarding drug and alcohol use, and the mandatory testing programs. I agree to full and unconditional compliance with the Department of Transportation regulations and The Company’s policies regarding drug and alcohol use and testing. I further understand and agree that I may be subject to disciplinary action and other liability for violating Department of Transportation and / or The Company’s policies.

Any questions or comments on drug and alcohol policies should be referred to the Drug and Alcohol Program contact person listed in the material provided to you.

Prior to signing this receipt, I read it carefully and had an opportunity to ask questions regarding its content.

_______________________________ _________________________________________________________________ Date Applicant’s Signature

_______________________________ _________________________________________________________________ Date Signature – Witness: Company Representative

PLEASE SEE ATTACHED SHEET FOR TEST RESULTS

CHECK THIS BOX IF THE APPLICANT IS A NON-CDL DRIVER


PRE-EMPLOYMENT DRUG AND ALCOHOL STATEMENT Previous Pre-Employment History of Applicant

CFR 49 Sec. 40.25(j): As an employer, you must ask the employee whether he or she has tested positive, or refused to test, on any pre-employment drug or alcohol test administered by an employer to which the employee applied for, but did not obtain, safety-sensitive transportation work covered by Department of Transportation drug and alcohol testing rules during the past two years. If the employee admits that he or she had a positive test or a refusal to test, you must not use the employee to perform safety-sensitive functions for you, until and unless the employee documents successful completion of the return-to-duty process. (See paragraphs (b)(5) and (e) of Section 40.25)


Applicant Name: _______________________________________________

Social Security Number: _________________________________________

The prospective employee is required by Section 40.24(j) to respond to the following questions:

1. Have you tested positive, or refused to test, on any pre-employment drug or alcohol test administered by an employer towhich you applied for, but did not obtain safety sensitive transportation work covered by Department of Transportationdrug and alcohol testing during the past two years?

Yes____ No____

2. If you answered Yes to question one, can you provide or obtain proof that you successfully completed the Department ofTransportation Return-To-Duty requirements?

Yes____ No____

______________________________ _________________________________________________________________ Date Signature of Applicant

______________________________ _________________________________________________________________ Date Signature of Witness

THE BELOW DISCLOSURE AND AUTHORIZATION LANGUAGE IS FOR MANDATORY USE BY

ALL ACCOUNT HOLDERS

Page 18

IMPORTANT DISCLOSURE REGARDING BACKGROUND REPORTS FROM THE PSP Online Service

In connection with your application for employment with _____________________________ (“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 it 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 supplying 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 Regulations (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 _______________________ (“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 supplying 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

Page 19

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: __________________________ _______________________________________

Signature

___________________________________________

Name (Please Print)

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

P.O. Box 9070 Wichita, KS 67277

Phone: (316) 942-9944 Fax: (316) 942-2941

APPLICANT NOTIFICATION AND RELEASE FORM

I understand that in the event I am hired and I choose to voluntarily terminate my relationship or if I am terminated with U.S. Road Freight Express, Inc. within my 6 months, any costs incurred by U.S. Road Freight Express, Inc. may be withh eld from my final paycheck .. These costs include physical examinations, drug screens, business cards, any items issued to me that are not returned or returned damage, etc.

I understand that in the event I am hired and am involved in a Preventable accident during the 6-month probation period, my employment with U.S. Road Freight Express, Inc. will be cause for termination of employment, I further understand that if during the 6-month probation period I am involved in a non-preventable accident, violate company policies, violate local, state or federal laws or regulations may be cause for termination.

Applicant Name Social Security Number

Applicant s Signature Date

Page 20

Documents

3655 S Maize Rd. Wichita, KS 67215 - US Road Freight Express · U.S. Road Freight Express, Inc. Attention: Safety Department/ Human Resources Dept. Telephone: 316-942-9944. Street: