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If you have any trouble with this application, please call 904-705-9946

- Step 1 of 19

To start the process of driving for JTK as an owner operator, we need to collect some information from you as part of our application process. This form will take about 15-20 minutes to fill out.

COLLECT THIS INFO BEFORE BEGINNING:

Before beginning the application, you need to have the following information available. We strongly recommend getting this information together beforehand:

Home address history for the past 3 years
Your driver's license
Employment history
History of traffic accidents, violations, and/or any convictions from the past 3 years
Information about any military history

REQUIREMENTS:

If any of the below is true, we will not be able to accept an application. If you’d like to discuss any concerns regarding these disqualifications or if you need any clarification on the below requirements, please call (904) 705-9946

You cannot have had a DUI within the last 5 years
Your truck must be ELD compatible
You must be at least 23 years old
You must have one year of verifiable Class A experience in the last three years
You have to pass the Federal DOT physical and drug screen
No more than 1 moving violation in the past 12 months and no more than 2 in the last 36 months
No DOT preventable, recordable accidents within the last 12 months
No history of reckless or careless driving in the last 36 months
Satisfactory work history (all past terminations will be reviewed and verified for any safety related issues)
If you have not already, upon completing this application you must register at the D&A Clearing House (instructions for doing so will be available after the last page of the application)

In compliance with Federal and State equal employment opportunity laws, qualified applicants are considered for all positions without regard to race, color, religion, sex, national origin, age, marital status, veteran status, non-job related disability, or any other protected group status

Personal Information

Name *

First

Last

Date of Birth *//

Address

Current Address *

Address Line 1

Address Line 2

City

State

Zip Code

Has this been your home address for 3 or more years?

If no, enter your previous home address:

Address Line 1

Address Line 2

City

State

Zip Code

Contact Information

Primary Phone *

Secondary Phone

Email Address *

Confirm Email

Preferred Method of Contact

Best Time to Contact You

Your Time Zone

General Information

Which types of freight have you hauled in the past 10 years? *

Government Services
Heavy Haul
Open Deck
Toter
Van

Are you legally eligible for employment in the United States? *

Have you registered for the Drug & Alcohol Clearinghouse? *

To learn more about the Clearinghouse and get registered, please visit their website.

Are you currently employed? *

If no, on what date did your last employment end? *

Do you read, write, and speak English? *

Do you have a current TWIC card? *

TWIC Expiration Date *//

Do you have a passport?

Are you a team driver?

Name of team driver:

Have you ever been known by any other name?

If so, please enter that name: *

Were you referred by a driver?

If so, which driver? (name and truck number)

In case of emergency, notify: (list name, address, and phone)

Driving Experience

For each class of equipment, enter the typeof equipment (van, reefer, tank, etc), start and end dates, and appropximate number of total miles. If you have no experience in a class, enter "none"

Straight Truck *

Tractor and Semi-Trailer *

Tractor - Two Trailers *

Other *

Total OTR years

If you have any safe driving awards, list them and who they are from here:

Equipment Description (Tractor):

Type:

Year

Make

Model

Color

VIN

Weight

Mileage

Fifth Wheel Height

Number of Axles

Is your truck ELD compliant?

Education

Highest level of education:

Last school attended (name, city, and state):

Personal References

First Reference

Name *

First

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone

Relationship

Second Reference

Name *

First

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone

Relationship

Business Discussion

We want to do our best to support your preferred running lanes and work diligently to understand and serve our owner operators needs. These questions aren't meant to qualify or disqualify you, but provide us with greater insight into how we can serve you better. Please answer the below questions to share with us what you expect from us:

What types of commodity have you hauled in the past 3 years?

Are you willing to run all 48 contiguous states? *

Please describe which area you prefer to run:

Have you ever worked with an Agent based system? *

Are you willing to tarp loads? *

How long have you been an Owner Operator?

What is your targeted weekly average net revenue? (after deductions - fuel, insurance, etc.) *

What is your expected home time? *

Truck and/or Trailer Payment Per Week ($):

Money Still Owed on Equipment ($):

Past Due Amount Owed on Equipment ($):

Any other additional information you would like to add:

License Information

License Number *

Country *

License State *

License Province *

License Expiration *//

Physical Expiration//

Is this your current driver license? *

Is this a commercial driver license? *

License Class *

Endorsements

None
Tanker
Doubles / Triples
Hazardous Materials
X Endorsement
Other

Hazmat expiration date: *//

If you checked 'other', please list what these endorsements are: *

Have you ever served in the military?

Branch of Service *

Start Date *//

End Date //

Rank at Discharge:

Can you obtain your DD214?

Have you been employed, contracted, or attented a company orientation in the past 10 years? *

Company Name *

Start Date *//

Are you currently still employed or contracted by this company? *

End Date *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone

Position Held *

Were you terminated/discharged/laid off? *

May we contact this employer at this time? *

Did you operate a commercial motor vehicle as part of this position? *

Have you ever been unemployed at any time within the last 10 years? *

Unemployment Information

Start Date//

End Date//

Comments

Driver Training

Have you ever attended a Driver Training School? *

Name of School *

Start Date *//

End Date *//

Country *

City *

State *

Province *

Phone

Did you graduate? *

Were you subject to the Federal Motor Carrier or Transport Canada Safety Regulations while attending this trucking school? *

Did you perform any safety sensitive functions at this trucking school, regulated by DOT, and subject to drug and alcohol testing? *

GPA

Total Hours of Instruction

Which of the following skills were trained in your program? (check all that apply)

Border Crossing
Log Books
Federal Motor Carrier Regulations
Hazardous Materials

FMCSR

Under FMCSR 391.15, are you currently disqualified from driving a commercial motor vehicle? [49 CFR 391.15] *

Has your license, permit, or privilege to drive ever been suspended or revoked for any reason? [49 CFR 391.21(b)(9)] *

Have you ever been denied a license, permit, or privilege to operate a motor vehicle? [49 CFR 391.21(b)(9)] *

Within the past two years, have you tested positive, or refused to test, on a pre-employment drug or alcohol test by an employer to whom you applied, but did not obtain, safety-sensitive transportation work covered by DOT agency drug and alcohol testing rules? [49 CFR 40.25(j)] *

In the past three (3) years, have you ever been convicted of any of the following offenses committed during on-duty time [49 C.F.R. 391.15 and 49 C.F.R. 395.2]:

Driving a commercial motor vehicle with a blood alcohol concentration ("BAC") of .04 percent or more
Driving under the influence of alcohol, as prescribed by state law
Refusal to undergo drug and alcohol testing as required by any jurisdiction for the enforcement of Federal Motor Carrier Safety Act regulations
Driving a commercial motor vehicle under the influence of any 21 C.F.R. 1308.11 Schedule I identified controlled substance, an amphetamine, a narcotic drug, a formulation of an amphetamine, or a derivative of a narcotic drug
Transportation, possession, or unlawful use of a 21 C.F.R. 1308.11 Schedule I identified controlled substance, amphetamines, narcotic drugs, formulations of an amphetamine, or derivatives of narcotic drugs while you were on duty driving for a motor carrier
Leaving the scene of an accident while operating a commercial motor vehicle
Or any other felony involving the use of a commercial motor vehicle

Have you had any moving violations or traffic convictions in the past 3 Years? *

Incident Details

How many moving violations or traffic convictions have you had in the past 3 years?

Violation Date *

Date

Time

Charge / Description *

State / Province *

Were you in a Commercial Vehicle? *

Penalty / Fine (check all that apply)

Fine
Suspension
Revocation
Community Service
Other

Fine Amount (if applicable)

If you answered "Other" to any of the above questions, please provide additional details:

Were you involved in any accidents/incidents with any vehicle in the last 5 years (even if not at fault)? *

Date of Accident / Incident *

Date

Time

Type of Accident / Incident

Hazmat Accident / Incident?

Was the vehicle towed away?

City

State / Province *

Were you in a commercial vehicle? *

Were you at fault? *

Were you ticketed? *

Please enter detailed information about this accident, whether the accident was chargeable, recordable, reportable, or your fault:

This certifies that this application was completed by you, and that all information in it are true and complete to the best of your knowledge.

Please enter your initials to sign your name below: *

A Summary of Your Rights Under the Fair Credit Reporting Act

Para información en español, visite www.consumerfinance.gov/learnmore o escribe a la Consumer Financial Protection Bureau, 1700 G Street N.W., Washington, DC 20552.

A Summary of Your Rights Under the Fair Credit Reporting Act

The federal Fair Credit Reporting Act (FCRA) promotes the accuracy, fairness, and privacy of information in the files of consumer reporting agencies. There are many types of consumer reporting agencies, including credit bureaus and specialty agencies (such as agencies that sell information about check writing histories, medical records, and rental history records). Here is a summary of your major rights under FCRA. For more information, including information about additional rights, go to www.consumerfinance.gov/learnmore or write to: Consumer Financial Protection Bureau, 1700 G Street N.W., Washington, DC 20552.

You must be told if information in your file has been used against you. Anyone who uses a credit report or another type of consumer report to deny your application for credit, insurance, or employment – or to take another adverse action against you – must tell you, and must give you the name, address, and phone number of the agency that provided the information.
You have the right to know what is in your file. You may request and obtain all the information about you in the files of a consumer reporting agency (your “file disclosure”). You will be required to provide proper identification, which may include your Social Security number. In many cases, the disclosure will be free. You are entitled to a free file disclosure if:
- a person has taken adverse action against you because of information in your credit report;
- you are the victim of identity theft and place a fraud alert in your file;
- your file contains inaccurate information as a result of fraud;
- you are on public assistance;oyou are unemployed but expect to apply for employment within 60 days.
In addition, all consumers are entitled to one free disclosure every 12 months upon request from each nationwide credit bureau and from nationwide specialty consumer reporting agencies. See www.consumerfinance.gov/learnmore for additional information.
You have the right to ask for a credit score. Credit scores are numerical summaries of your credit-worthiness based on information from credit bureaus. You may request a credit score from consumer reporting agencies that create scores or distribute scores used in residential real property loans, but you will have to pay for it. In some mortgage transactions, you will receive credit score information for free from the mortgage lender.
You have the right to dispute incomplete or inaccurate information. If you identify information in your file that is incomplete or inaccurate, and report it to the consumer reporting agency, the agency must investigate unless your dispute is frivolous. See www.consumerfinance.gov/learnmore for an explanation of dispute procedures.
Consumer reporting agencies must correct or delete inaccurate, incomplete, or unverifiable information. Inaccurate, incomplete, or unverifiable information must be removed or corrected, usually within 30 days. However, a consumer reporting agency may continue to report information it has verified as accurate.
Consumer reporting agencies may not report outdated negative information. In most cases, a consumer reporting agency may not report negative information that is more than seven years old, or bankruptcies that are more than 10 years old.
Access to your file is limited. A consumer reporting agency may provide information about you only to people with a valid need – usually to consider an application with a creditor, insurer, employer, landlord, or other business. The FCRA specifies those with a valid need for access.
You must give your consent for reports to be provided to employers. A consumer reporting agency may not give out information about you to your employer, or a potential employer, without your written consent given to the employer. Written consent generally is not required in the trucking industry. For more information, go to www.consumerfinance.gov/learnmore.
You may limit “prescreened” offers of credit and insurance you get based on information in your credit report. Unsolicited “prescreened” offers for credit and insurance must include a toll-free phone number you can call if you choose to remove your name and address form the lists these offers are based on. You may opt out with the nationwide credit bureaus at 1-888-5- OPTOUT (1-888-567-8688).
The following FCRA right applies with respect to nationwide consumer reporting agencies:

CONSUMERS HAVE THE RIGHT TO OBTAIN A SECURITY FREEZE

You have a right to place a “security freeze” on your credit report, which will prohibit a consumer reporting agency from releasing information in your credit report without your express authorization. The security freeze is designed to prevent credit, loans, and services from being approved in your name without your consent. However, you should be aware that using a security freeze to take control over who gets access to the personal and financial information in your credit report may delay, interfere with, or prohibit the timely approval of any subsequent request or application you make regarding a new loan, credit, mortgage, or any other account involving the extension of credit.

As an alternative to a security freeze, you have the right to place an initial or extended fraud alert on your credit file at no cost. An initial fraud alert is a 1-year alert that is placed on a consumer’s credit file. Upon seeing a fraud alert display on a consumer’s credit file, a business is required to take steps to verify the consumer’s identity before extending new credit. If you are a victim of identity theft, you are entitled to an extended fraud alert, which is a fraud alert lasting 7 years.

A security freeze does not apply to a person or entity, or its affiliates, or collection agencies acting on behalf of the person or entity, with which you have an existing account that requests information in your credit report for the purposes of reviewing or collecting the account. Reviewing the account includes activities related to account maintenance, monitoring, credit line increases, and account upgrades and enhancements.
You may seek damages from violators. If a consumer reporting agency, or, in some cases, a user of consumer reports or a furnisher of information to a consumer reporting agency violates the FCRA, you may be able to sue in state or federal court.
Identity theft victims and active duty military personnel have additional rights. For more information, visit www.consumerfinance.gov/learnmore.

States may enforce the FCRA, and many states have their own consumer reporting laws. In some cases, you may have more rights under state law. For more information, contact your state or local consumer protection agency or your state Attorney General. For information about your federal rights, contact:

TYPE OF BUSINESS:	CONTACT:
1.a. Banks, savings associations, and credit unions with total assets of over $10 billion and their affiliates b. Such affiliates that are not banks, savings associations, or credit unions also should list, in addition to the CFPB:	a.Consumer Financial Protection Bureau 1700 G Street, N.W. Washington, DC 20552 b. Federal Trade Commission Consumer Response Center 600 Pennsylvania Avenue, N.W. Washington, DC 20580 (877) 382-4357
2. To the extent not included in item 1 above: a. National banks, federal savings associations, and federal branches and federal agencies of foreign banks b. State member banks, branches and agencies of foreign banks (other than federal branches, federal agencies, and Insured State Branches of Foreign Banks), commercial lending companies owned or controlled by foreign banks, and organizations operating under section 25 or 25A of the Federal Reserve Act. c. Nonmember Insured Banks, Insured State Branches of Foreign Banks, and insured state savings associations d. Federal Credit Unions	a. Office of the Comptroller of the Currency Customer Assistance Group 1301 McKinney Street, Suite 3450 Houston, TX 77010-9050 b. Federal Reserve Consumer Help Center P.O. Box 1200 Minneapolis, MN 55480 c. FDIC Consumer Response Center 1100 Walnut Street, Box #11 Kansas City, MO 64106 d. National Credit Union Administration Office of Consumer Financial Protection (OCFP) Division of Consumer Compliance Policy and Outreach 1775 Duke Street Alexandria, VA 22314
3. Air Carriers	Asst. General Counsel for Aviation Enforcement & Proceedings Aviation Consumer Protection Division Department of Transportation 1200 New Jersey Avenue, S.E. Washington, DC 20590
4.Creditors Subject to the Surface Transportation Board	Office of Proceedings, Surface Transportation Board Department of Transportation 395 E Street, S.W. Washington, DC 20423
5. Creditors Subjectto the Packers and StockyardsAct, 1921	Nearest Packers and Stockyards Administration area supervisor
6. Small Business Investment Companies	Associate Deputy Administrator for Capital Access United States Small Business Administration 409 Third Street, S.W., Suite 8200 Washington, DC 20416
7. Brokers and Dealers	Securities and Exchange Commission 100 F Street, N.E. Washington, DC 20549
8. Federal Land Banks, Federal Land Bank Associations, Federal Intermediate Credit Banks, and Production Credit Associations	Farm Credit Administration 1501 Farm Credit Drive McLean, VA 22102-5090
9. Retailers, Finance Companies, and All Other Creditors Not Listed Above	Federal Trade Commission Consumer Response Center 600 Pennsylvania Avenue, N.W. Washington, DC 20580 (877) 382-4357

By checking this box, I (a) acknowledge that I have read and understand the federal FCRA Summary of Rights and have been given the opportunity to copy/print the Summary of Rights and (b) agree to use an electronic signature to demonstrate my consent.

An electronic signature is as legally binding as an ink signature.

The Below Disclosure and Authorization Language is for Mandatory Use by All Account Holders

REGARDING BACKGROUND REPORTS FROM THE PSP Online Service

In connection with your application for employment with JTK Trucking ("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 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) crashed where you were a driver or co-drive 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 Irish Express, Inc. (“Prospective Employer”) to access the FMCSA Pre-Employment Screening Programs (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 violation, 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.

By checking this box, I (a) acknowledge that I have read and understand the PSP Disclosure and Authorization and have been given the opportunity to copy/print it and (b) agree to use an electronic signature to demonstrate my consent.

An electronic signature is as legally binding as an ink signature.

Disclosure and Release

In connection with your employment or application for employment (including contract for services) through Bennett Motor Express, consumer reports (Investigative Consumer Reports in California) may be requested from HireRight (formerly USIS Commercial Services) and Asurint. These reports may include the following types of information: names and dates of previous employers, reasons for termination of employment, work experience, accidents, academic history, professional credentials and drug/alcohol use. Such reports may contain public record information concerning your driving record, workers' compensation claims, credit, bankruptcy proceedings, criminal records, etc. from federal, state and other agencies that maintain such records; as well as information from HireRight and Asurint concerning previous driving record requests made by others from such state agencies and state provided driving records.

We also will obtain driving/accident and safety inspection history records maintained by the Federal Motor Carrier Safety Administration ("FMCSA").

You have the right to make a request to HireRight and Asurint, upon proper identification, to request the nature and substance of all information in its files on you at the time of your request, including the explaining of any coded information, the sources of information and the recipients of any reports on your that HireRight has previously furnished within the past two year period preceding your request (3 years in California). HireRight may be contacted by mail at P.O. Box 33181, Tulsa,OK 74153 or by telephone at 800-381-0645. You may also bring a third party with you to view the information at the HireRight offices if this person provides proper identification. Information about HireRight's privacy practices is available at www.hireright.com/Privacy-Policy.aspx. Asurint may be contacted by mail at Compliance Dept, PO Box 14730, Cleveland, Ohio44114 or by telephone at (800) 906-2034 or by email at compliance@asurint.com. Their website is https://www.asurint.com/candidates.

I AUTHORIZE, WITHOUT RESERVATION, HIRERIGHT AND ASURINT, FMCSA AND ANY OTHER PARTY OR AGENCY CONTACTED BY HIRERIGHT TO FURNISH THE ABOVE MENTIONED INFORMATION. THIS AUTHORIZATION DOES NOT APPLY TO DRUG AND ALCOHOL INFORMATION CONTAINED UNDER PART I.

I hereby consent to your obtaining the above information from HireRight and Asurint, and I agree that such information which HireRight and Asurint has or obtains in my employment history (not DOT drug and alcohol information without a specific consent by me) with you if I am hired, will be supplied by HireRight and Asurint. I hereby authorize procurement of consumer reports as set forth above.

If hired or contracted, this authorization for reports covered by this release only shall remain on file and shall serve as an ongoing authorization for your to procure consumer reports at any time during my employment or contract period.

I consent to you obtaining the above information from FMCSA. I understand that the FMCSA maintains sole control over that data and you cannot change or alter such information. If I dispute any information maintained by FMCSA, I must personally contact the FMCSA by accessing the DataQs system at: https://dataqs.fmcsa.dot.gov.

By checking this box, I (a) acknowledge that I have read and understand the above and have been given the opportunity to copy/print it and (b) agree to use an electronic signature to demonstrate my consent.

An electronic signature is as legally binding as an ink signature.

Disclosure and Release

DISCLOSURE AND RELEASE

In accordance with DOT Regulation 49 CFR Part 391.23, I authorize the release of information from my DOT regulated drug and alcohol testing records by the carriers (company/school) listed above to Bennett Motor Express, or to HireRight or to Asurint for the sole purpose of transmitting such records to Bennett Motor Express. I authorize release of the following information concerning DOT drug and alcohol testing violations including pre-employment tests during the past three years: (i) alcohol tests with a result of 0.04 or higher; (ii) verified positive drug tests; (iii) refusals to be tested (including verified adulterated or substituted results); (iv) other violations of DOT drug and alcohol testing regulations; (v) information obtained from previous employers of a drug and alcohol rule violation(s); and (vi) documents, if any, of completion of a return-to-duty process following a rule violation. I also authorize the carriers (company/school) listed above to release information about names and dates of previous employers, reasons for termination of employment, work experience, accidents, academic history, professional credentials and other information.

The information that I have authorized Bennett Motor Express or HireRight or Asurint to review involves tests required by DOT. If any carrier (company/school) listed above furnishes Bennett Motor Express or HireRight or Asurint with information concerning items (i) through (vi) above, I also authorize that carrier (company/school) to release and furnish the dates of my negative drug and/or alcohol tests and/or tests with results below 0.04 during the three-year period and the name and phone number of any substance abuse professional who evaluated me during the past three years.

By checking the box, I (a) acknowledge that I have read and understand the above and also have been given the opportunity to copy/print it, and (b) agree to use an electronic signature to demonstrate my consent.

An electronic signature is as legally binding as an ink signature.

Consent Form

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

I hereby provide consent to Bennett Motor Express 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. I understand this consent shall remain on file and shall serve as ongoing consent for Bennett Motor Express to conduct multiple limited queries of the Clearinghouse at any time during my employment or contract period without asking me for additional consent.

I understand that if I refuse to provide consent for Bennett Motor Express to conduct a limited query of the Clearinghouse, Bennett Motor Express is required to prohibit me from performing safety-sensitive functions, including operating a commercial motor vehicle.

I understand that if the limited query conducted by Bennett Motor Express indicates that drug or alcohol information exists about me in the Clearinghouse, the FMCSA will not disclose that information to Bennett Motor Express unless I give additional specific consent within the Clearinghouse. However, I understand that Bennett Motor Express will be required to conduct a full query of the Clearinghouse within 24 hours after a limited query indicates that drug or alcohol information exists and that if I do not grant consent within the Clearinghouse for that full query I will be removed from performing safety-sensitive functions, including operating a commercial motor vehicle.

By checking the box, I (a) acknowledge that I have read and understand the above and also have been given the opportunity to copy/print it, and (b) agree to use an electronic signature to demonstrate my consent.

An electronic signature is as legally binding as an ink signature.

COLLECT THIS INFO BEFORE BEGINNING:

REQUIREMENTS:

Personal Information

Address

Contact Information

General Information

Driving Experience

Equipment Description (Tractor):

Education

Personal References

First Reference

Second Reference

Business Discussion

License Information

Unemployment Information

Driver Training

FMCSR

Incident Details

This certifies that this application was completed by you, and that all information in it are true and complete to the best of your knowledge.

A Summary of Your Rights Under the Fair Credit Reporting Act

A Summary of Your Rights Under the Fair Credit Reporting Act

The Below Disclosure and Authorization Language is for Mandatory Use by All Account Holders

REGARDING BACKGROUND REPORTS FROM THE PSP Online Service

AUTHORIZATION

Disclosure and Release

Disclosure and Release

DISCLOSURE AND RELEASE

Consent Form

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

Terry Bailey