APPLICATION TO COMPLETE

EMPLOYMENT HISTORY

All applicants must provide the following information on all employers during the preceding 3 years. List complete mailing address and contact information.

All applicants to drive a commercial motor vehicle* in intrastate or interstate commerce shall also provide an additional 7 years’ information on those employers for who the applicant operated such vehicle.

(NOTE: List employers in reverse order starting with the most recent.)

*Includes vehicles having a GVWR OF26,001 lbs or more, vehicles designed to transport 16 or more passengers (including the driver), or any size vehicle used to transport hazardous materials in a quantity requiring place carding.

†The Federal Motor Carrier Safety Regulations (FMCSRs) 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 more than 8 passengers (including the driver), OR (3) is of any size and is used to transport hazardous materials in a quantity requiring place carding.

ACCIDENT RECORD

TRAFFIC CONVICTIONS & FORFEITURES

EXPERIENCE AND QUALIFICATIONS- DRIVER

DRIVING EXPERIENCE

Select Yes or No if you have experience with the below classes of equipment. If you answer ‘Yes’, also indicate the type of equipment operated in the class, number of years of experience and approximate number of miles.

OTHER EXPERIENCE AND QUALIFICATIONS

EDUCATION

TO BE READ AND SIGNED BY APPLICANT

Driver Applicant Drug and Alcohol
Pre-Employment Statement and Consent

Pre-Employment Drug or Alcohol Test for Previous Employers

49 CFR Part 40.25(j) requires an employer to ask any applicant 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 DOT agency drug and alcohol testing rules during the past two years. If the applicant admits that he or she had a positive test or a refusal to test, BCP Transportation, Inc. (“Company”) must not use the applicant to perform safety-sensitive functions, until and unless the applicant documents successful completion of the return-to-duty process (see section 49 CFR Part 40.25 (b)(5) and (e)).

As an applicant applying to perform safety-sensitive functions for the Company, you are required by 49 CFR Part 40.25(j) to respond to the following questions:

PRE-EMPLOYMENT DRUG TESTING NOTIFICATION AND CONSENT

I understand that, as required by the Federal Motor Carrier Safety Regulations 49 CFR Part 382 and Company policy, all prospective drivers must submit to a controlled substances test involving collection of a urine sample that will be tested for the following controlled substances: marijuana, cocaine, opiates, amphetamines and phencyclidine (PCP).

I understand that, if I test positive for use of controlled substances, I am not medically qualified to operate a commercial motor vehicle. I also understand I will be given a reasonable opportunity to confer with the Company’s medical review officer before any positive drug test result is reported to the Company. The results of the drug tests will be maintained by the medical review officer of the Company, who will report to the Company whether the test result was negative or positive. The results of any tests will not be released to any additional parties, except as provided in 49 CFR Part 40.37, without my written authorization.

TO BE READ AND SIGNED BY APPLICANT

Driver Applicant Consent for Previous Employer
Drug and Alcohol Testing and Safety Performance History

In accordance with FMCSA Regulation 49 CFR Part 391.23, I understand that BCP Transportation, Inc. (“Company”) will perform an investigation of my safety performance history with Department of Transportation (“DOT”) regulated employers during the preceding three years from the date shown below. I acknowledge that this information will be used in determining my eligibility to be hired, and that I have the right to review this information and rebut any errors in the statements from previous employers, as described in the FMCSA Regulation 49 CFR Part 391.23(i)(1).

DISCLOSURE AND RELEASE

1. I authorize the release of information from my DOT regulated drug and alcohol testing records by the previous employer listed below to the Company, and any agent acting on their behalf, for the sole purpose of transmitting such records to the Company. 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 alcohol concentration; (ii) verified positive drug tests; (iii) refusals to be tested (including verified adulterated or substituted drug test 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, to include SAP information and follow-up tests and/or documentation of non-completion or refusal of SAP referral and all testing violations subsequent to the successful completion of a rehabilitation SAP.

2. I authorize the release of my safety performance history information, as described in 49 CFR Part 391.23(d), by the previous employer listed below to the Company.

3. I authorize the release of employment information as requested by the Company to the previous employer listed below as they pertain to my application for employment, including, but not limited to, names and dates of previous employers, reasons for termination of employment, work experience, accidents, academic history, professional credentials, and training courses completed.

4. I hereby release the previous employer listed below, and its employees, officers, directors, and agents from any and all liability of any type as a result of providing information to the Company.

Driver Applicant Background Reports
Disclosure and Release

In connection with your employment or application for employment (including contract for services) through BCP Transportation, Inc. (“Company”), consumer reports (Investigative Consumer Reports in California) may be requested from HireRight, Inc. (“HireRight”). 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 concerning previous driving record requests made by others from such state agencies and state provided driving records.

BCP Transportation, Inc., will also 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, 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 you that HireRight has previously furnished within the past two year period preceding your request (3 years in California). HireRight is located and can be contacted at 3349 Michelson Drive, Suite 150, Irvine, CA 92612, (800) 400-2761, www.hireright.com. 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.

I AUTHROIZE, WTHOUT RESERVATION, HIRERIGHT, FMCSA, AND ANY OTHER PARTY OR AGENCY CONTACTACTED BY HIRERIGHT TO FURNISH THE ABOVE MENTIONED INFORMATION. THIS AUTHORIZATION DOES NOT APPLY TO DRUG AND ALCOHOL INFORMATION CONTAINED UNDER THE CONSENT FOR PREVIOUS EMPLOYER DRUG AND ALCOHOL TESTING AND SAFETY PERFORMANCE HISTORY.

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

I hereby consent to the Company obtaining the above information from FMCSA. I understand that neither the Company nor the FMCSA contractor supplying the crash and safety information has the capability to correct any safety data that appears to be incorrect. If I challenge the accuracy of the data, a request must be submitted to https://dataqs.fmcsa.dot.gov. If crash or inspection information reported by a State is challenged, FMCSA cannot change or correct this data. Requests 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 Pre-Employment Screening Program (“PSP”) report. Since the PSP report does not report, or assign, or imply fault, I understand it will include all Commercial Motor Vehicle (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, appear on the PSP report and that 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.

TO BE SIGNED BY APPLICANT

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 BCP 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.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 BCP 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 as a 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.