Application For Employment


Employment Record for the Past 10 Years

Begin with your present or most recent job and work backward in order, listing your employers for the past 10 years, including all full and part-time employment. All information must be provided. You must account for all time including all military service, self employment, and periods of unemployment. Use supplemental sheet if necessary.

Experience and Qualifications

Driving Experience

Accident Report

List all traffic accidents which you have been involved in for the past 5 years. Include chargeable and non chargeable.

Traffic Convictions

List all traffic convictions for the past 5 years, excluding parking violations.

Criminal Convictions

Have you ever been convicted of the following:

Please note: A conviction is not an automatic bar to employment. All circumstances will be considered including: the time since the offense, evidence of rehabilitation and the nature of the offense and its relationship to the Company’s business.

AGREEMENT

Please read this Agreement and sign below, if you understand and agree to its terms. If you have any questions or need any explanation, please ask now.

It is agreed and understood that any misrepresentation of information shall be considered an act of dishonesty.

I understand that the information in this application will be used and that past or present employers will be contacted for purposes of investigation as required by the Federal Department of Transportation Regulations.

You are hereby notified of your due process rights as specified in 391.23i(1) of the Federal Motor Carrier Safety Regulations. 1: The right to review information provided by previous employers; 2: The right to have errors in the information corrected by the previous employer and for that previous employer to re-send the corrected information to the prospective employer; 3: The right to have a rebuttal statement attached to the alleged erroneous information, if the previous employer and the driver cannot agree on the accuracy of the information.

It is agreed and understood that Ploger Transportation, LLC or its Agents may investigate my background to ascertain any and all information of concern to my record, whether that information is of record or not, and I release all former employers, driving schools, and persons named in the employment record section of this document from all liability for any damage caused by the release of such information

I further understand that as a result of making this application for employment my criminal record may be examined by Ploger Transportation, LLC or its Agents, I hereby authorize Ploger Transportation, LLC or its designated Agents to make any lawful examination of my criminal record.

I understand that at any time in the future, whether actively employed by Ploger Transportation, LLC or not, that upon the request of any party or any surety, Ploger Transportation, LLC may furnish reports and information relative to my record and service with Ploger Transportation, LLC. I agree that this information may be furnished without liability or damages on behalf of Ploger Transportation, LLC.

As part of the pre-employment process, a medical examination, including drug testing, will be required after a conditional offer of employment. I further agree to provide access to previous medical records if required.

I understand and agree that the DOT physical examination shall include substance screening.

I understand and agree that Ploger Transportation, LLC reserves the right to use substance tests 1) at random, 2) for reasonable cause, 3) after any accident.

I agree to furnish any additional information and complete any examinations that may be required to complete my employment application.

Withholding, omitting or falsifying any information used in the consideration of my application may result in the rejection of my application or the termination of my employment.

I understand that during the term of my at-will employment, I will comply with the guidelines set forth in Ploger Transportation, LLC policies, rules, regulations and procedures, which shall be amended from time to time. I also agree that my at-will employment and compensation can be terminated with or without cause and without notice or liability whatsoever, at any time, at the option of either Ploger Transportation, LLC or myself.

I understand and agree that this application for employment in no way obligates Ploger Transportation, LLC to employ me.

I consent to the procurement of any consumer reports, including reports from DAC Services, Inc., deemed necessary by Ploger Transportation, LLC or it subsidiaries in their consideration of my employment.

This application was completed by me, and all entries on it and the information that I have provided in the application are true and complete to the best of my knowledge. Any misrepresentation or omission of any fact in my application, resume or any other materials submitted to Ploger Transportation, LLC or during my interviews (pre- and post-offers of employment) may result in denial of employment or discharge.

I have read and I understand all of this Agreement.

IMPORTANT DISCLOSURE REGARDING BACKGROUND REPORTS FROM THE PSP Online Service

In connection with your application for employment with Ploger Transportation ("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.frncsa.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 FMC SA, 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 FMC SA without your authorization.

Application Authorization

If you agree that the Prospective Employer may obtain such background reports, please read the following and sign below:

I authorize Ploger Transportation ("'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.

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.

NOTICE: The prospective employment concept referenced in this form contemplates the definition of "employee" contained at 49 C.F.R. 383.5.

LAST UPDATED 12/22/2015