Job Application Form Please fill in the form below. All fields marked with (*) are required. To sign the document click and drag within the signature field. AJ Freight Systems 679 East South Frontage Road, Bolingbrook,IL 60440 Tel: 630-754-8353 Fax: 630-754-8354 Driver Application In compliance with federal and state equal opportunity laws, qualified applicants are considered for all positions without regard to race, religion, sex, national origin, age, marital status, or non-job related disabiliy. TO BE READ AND SIGNED BY APPLICANT 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 investigation my safety performance history as required by 49 CFR 391.23(d) and (e). I also understand that AJ Freight Systems Inc. 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 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 Date*(required): Name*(required): Email*(required): Please sign here DRIVER NAME ADDRESS CITY: STATE: ZIP PHONE NUMBER CELL NUMBER FAX NUMBER E-MAIL DATE OF BIRTH SOCIAL SECURITY NUMBER CDL NUMBER STATE Issued ARE YOU LEGALLY AUTHORIZED TO WORK IN THE U.S. ? Yes No Please Upload a valid copy of your drivers license:(required) Expiration date of your drivers license: Please upload a valid copy of your medical card: Please upload a valid copy of your Motor Vehicle record: HOW MANY YEARS OF EXPERIENCE DO YOU HAVE TYPE OF EQUIPMENT APPROXIMATELY DRIVEN MILES PREVIOUS ADDRESSES FOR THE PAST THREE (3) YEARS (1) ADDRESS: STATE: CITY: ZIP: FROM: TO: (2) ADDRESS: STATE: CITY: ZIP: FROM: TO: (3) ADDRESS: STATE: CITY: ZIP: FROM: TO: WORK EXPERIENCE DRIVER APPLICANT NAME: SOCIAL SECURITY NUMBER: In accordance with 391.21 & .23 of the Federal Motor Carrier Safety Regulations (FMCSR), an applicant must list all previous work experience for the three (3) years prior to the date of application shown on page one, as well as all commercial driving experience for seven (7) years prior to those three years, for a total of 10 years. PLEASE LIST STARTING WITH MOST RECENT EMPLOYER CURRENT OR LAST EMPLOYER COMPANY NAME: MC#: ADDRESS: CITY: STATE: ZIP: PHONE: FAX: E-MAIL: CONTACT PERSON: REASON FOR LEAVING? JOB DESCRIPTION: From: To: CFR Part 40? Yes No *Was this job subject to FMCSA Regulations?: Yes No **ACCOUNT FOR PERIOD BETWEEN JOBS (include reason): SECOND TO LAST EMPLOYER COMPANY NAME: MC#: ADDRESS: CITY: STATE: ZIP: PHONE: FAX: E-MAIL: CONTACT PERSON: REASON FOR LEAVING? JOB DESCRIPTION: From: To: CFR Part 40? Yes No *Was this job subject to FMCSA Regulations?: Yes No **ACCOUNT FOR PERIOD BETWEEN JOBS (include reason): THIRD TO LAST EMPLOYER COMPANY NAME: MC#: ADDRESS: CITY: STATE: ZIP: PHONE: FAX: E-MAIL: CONTACT PERSON: REASON FOR LEAVING? JOB DESCRIPTION: From: To: CFR Part 40? Yes No *Was this job subject to FMCSA Regulations?: Yes No **ACCOUNT FOR PERIOD BETWEEN JOBS (include reason): * The Federal Motor Carrier Safety Regulations apply to anyone operating a motor vehicle on a highway in interstate commerce to transport passengers or property when the vehicle: 1) weighs or has a GVWR of 10,001 pounds or more, 2) is designed or used to transport 9 or more passengers, or 3) is of any size and is used to transport hazardous materials in a requiring pleading. ** Any gaps in employment and/or unemployment must be explained. Applicant Signature Date DISCLOSURE AND RELEASE FORM EMPLOYEE DRIVING RECORD INFORMATION 1. Because I must drive as an essential function of my employment or potential employment, I hereby give permission to AJ Freight Systems Inc. to obtain my state driving record (also known as my motor vehicle record or MVR) in accordance with the Fair Credit Reporting Act (FCRA) and the Federal Driver’s Privacy Protection Act (DPPA). 2. I acknowledge and understand that my driving record is a consumer report that contains public record information. 3. I authorize, without reservation any party or agency contacted by AJ Freight Systems Inc. to furnish AJ Freight Systems Inc. a copy of my state driving record. 4. I understand that I have the right to request a copy of my driving record and to know the source or sources of my driving record, for a two-year period preceding my request. 5. This authorization shall remain on file by AJ Freight Systems Inc. for the duration of my employment, and will serve as ongoing authorization for AJ Freight Systems Inc. to procure my state driving record at any time during my employment period. 6. I understand that AJ Freight Systems Inc. may take adverse action affecting my employment, based on information in my driving record. If such adverse action is taken, I acknowledge that my rights are as follows: ● Employer must notify me in writing of any such adverse action ● I have the right to receive a copy of the driving record upon which the adverse action was based. ● I have the right to receive a summary of my rights under the Fair Credit Reporting Act. I have the right to know the name, address and phone number of the consumer reporting agency that provided my driving record to AJ Freight Systems Inc.. ● I have the right to obtain a free copy of my driving record from the agency that provided it, if such request is made within 60 days from the date that Employer took adverse action. ● I have the right to dispute the accuracy or completeness of my driving record with the consumer reporting agency that provided it, and request that errors be corrected. 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. (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 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 interviews may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the Company. I understand information I provide regarding current and/or previous employers may be used, and those employers 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 the 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 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. This certifies 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. In accordance with the provisions of Section 604 (b)(2)(A) of the Fair Credit Reporting Act, Public Law 91-508, as amended by the Consumer Credit Reporting Act of 1996 (Title II, Subtitle D, Chapter I, of Public Law 104-208), you are being informed that reports verifying your previous employment, previous drug and alcohol test results, and your driving record may be obtained on you for employment purposes. Your employer may obtain this information from Equifax, TransUnion, Experian or other vendors of information services. Name: Date: Signature here: Social Security Number Driver’s License Number State Date of Birth PLEASE READ THE DISCLOSURE AND AUTHORIZATION STATEMENT PRIOR TO SIGNING THIS AUTHORIZATION FORM I have carefully read and understood this Disclosure and Authorization Statement and the FTC summary of rights under the Fair Credit Reporting Act (“FCRA”). By my signature below, I consent to the release of consumer reports, investigative consumer reports, and other personal history reports prepared by a consumer reporting agency, government agency or department, or other entity to AJ Freight Systems Inc. (the “Company”). I understand that if the Company hires me, my consent will apply, and the company may obtain the reports, throughout my employment. I also understand that information contained in my job application or otherwise disclosed by me before or during my employment, if any, may be used for the purpose of obtaining Consumer reports and/or investigative consumer reports. By my signature below, I authorize law enforcement agencies, learning institutions (including public and private schools and universities), information service bureaus, credit bureaus, record/data repositories, courts (federal, state and local), motor vehicle records agencies, my past or present employers, the military, and other individuals and sources to furnish any and all information on me that is requested by the consumer reporting agency. Furthermore, Customers of the Company may require investigative or consumer reports which apply to my background. These reports would apply to my assessment to projects related to the Customer, permission to be on the Customers premises and to handle its products and other security concerns of the Customer. I agree to allow the Company to provide my work history information to a consumer reporting agency. I understand that I have the right to review information provided by my previous employers, to have errors corrected by the previous employers and re-send to the Company once corrected, and to have a rebuttal statement attached to any alleged erroneous information should my previous employer and I not agree on the accuracy of the information. I further understand that the information provided by me will be used in making employment determinations and that my previous employer will be contacted for the purpose of investigating my safety performance history information as required by paragraphs (d) and (e) of “49 CFR” Part 391.23. Request to review previous employer information must be in writing. A release form for employment records can be requested by calling 630-754-8353 ext. 403, or mail to Safety Department AJ Freight Systems Inc. 716 Pinetree Ct. Romeoville, IL 60446. I understand that I have additional rights under the FCRA as noted in the FTC summary of rights provided to me. I hereby authorize any person or company for whom I have worked (as an employee or contractor), whether listed below or not, to furnish information they may have pertaining to my character, habits, financial responsibility, job performance, reasons for leaving employment, and all information concerning my employment or training. I hereby release all persons and organizations from any claims from damages of any kind. By my signature below, I certify the information I provided on my application is true and correct. I agree that this Disclosure and Authorization form in original, faxed, photocopied or electronic (including electronically signed form) will be valid for any reports that may be requested by or on behalf of the Company. Previous Employer: Printed name: Signature: Social Security Number: Telephone number: Signed date: SAFETY PERFORMANCE HISTORY REQUEST The person named herein has applied to AJ Freight Systems Inc., for employment in a safety-sensitive position. I, the listed applicant below, hereby authorize the following company(s) to release all records of employment, including assessments of my job performance, ability, fitness and drug testing results to AJ Freight Systems Inc., 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 the following information to the above-mentioned company. The applicant’s signature on this form releases all liability of you and your company. Information is being requested in accordance with 49 CFR Parts 40, 382 and 391. Applicant’s Signature Date Previous Company: Address: Tel: Fax: E-mail: Name of Applicant: Social Security Number: ------------------------------------------------------------------- Drivers do not fill out below this line-For official use only Dates of employment: From_______/______/______ To ______/______/______ Full Time: ______ Part-Time:______ Position(s) Held: _____________________ Local: _____ Regional: ______ Over-the-Road:______ Did this driver operate commercial motor vehicles greater than 26,000 lbs GVWR? ___yes ___no Type of equipment operated: Dry Van Flatbed Reefer Other (please list): __________ Reason for leaving: ___Voluntary ___Lay-Off ___Terminated ___Retired If terminated, why? Eligible for rehire? ______Yes ______No _______Upon Review _______No, Company Policy: __________ Motor Vehicle Accident/Equipment Damage/Incident Inquiry, If no accidents please check box  none Accident Date City, State Did the Accident Involve? Brief Description ___/___/___ Tow Injury Fatality HM Release ________________________________ ___/___/___ Tow Injury Fatality HM Release ________________________________ ___/___/___ Tow Injury Fatality HM Release ________________________________ Alcohol & Controlled Substance Testing Inquiry Has this driver ever had a breath alcohol test within the past 3 years a result of 0.04 or higher alcohol concentration? ___yes ___no Has this driver ever had a positive drug test in the past 3 years? ___yes ___no Has this driver refused a controlled substance test and/or alcohol test within the past 3 years? ___yes ___no Has this driver violated any other DOT drug/alcohol regulation? ___yes ___no To your knowledge has this driver violated any DOT drug and alcohol regulations at a previous employer? ___yes ___no **If the answer to any of the above questions is “Yes”, please provide details below: Reason for test(s): _______________Result of test(s): __________________________Date of test(s):____________________ If the applicant tested positive, to your knowledge, have they satisfactorily completed all return to duty and follow-up testing requirements in accordance 49 CFR 382.503? ________YES _________NO Any other remarks:________________________________________________________ Verification Completed By: ________________________________________________________ Title: ________________________________ Phone Number: _____________________________ Verification Date: _____________________ ================================================================================================== First Request Date: ___/___/___ Second Request Date: ___/___/___ Third Request Date: ___/___/___ Fax___ Mail ___ Phone ___ Fax ___ Mail ___ Phone ____ Fax ___ Mail___ Phone ____ Initials __ Initials Initials__________ 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 AJ Freight Systems 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 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 AJ Freight Systems 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 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 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 Name Please check this box: I understand and agree with all that has been written in this agreement. As such I validate that my signature is my own and that I am fully aware of all the terms and conditions set within this agreement. Please place your signature here 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.