Join Our Expanding Team

Employment for the Past 10 Years

ATTACH ADDITIONAL SHEETS AS NECESSARY

Military Status

Education

Driver Qualifications

LIST ALL

DRIVERS LICENSES

HELD DURING

PREVIOUS 10 YEARS

If the answer to either A or B is yes, attach statement giving details

DRIVING EXPERIENCE

CLASS(STRAIGHT TRUCK )

CLASS(TRACTOR/TRAILER )

CLASS(DOUBLES, TRIPLES )

CLASS(OTHER)

Maintenance Qualifications

EQUIPMENT YOU CAN OPERATE / REPAIR

Clerical Qualifications

INDICATE TRAINING AND EXPERIENCE IN THE FOLLOWING

To Be Read and Signed by Applicant

This certifies that I prepared this application and that all information is true and complete. I authorize you to make investigations as to my employment, medical, financial, and other related matters necessary to make an employment decision. I hereby release anyone responding to these investigations of all liability related to the release of such information. I understand that false and misleading information in this application and interview(s), is cause for dismissal. If hired, I agree to abide by all lawful rules and regulations of the company.

Past Employment Verification

Requested by: JT BARRIER LLC  12301 New Ave., Suite E. Lemont, IL 60439
Phone: (630) 312-8701
Fax: (630) 312-8742

Previous Employer: The below driver has made application with our Company and states that s/he worked for you in the past. We appreciate your time completing, in confidence, the information requested below.

Important Disclosure

REGARDING BACKGROUND REPORTS FROM THE PSP Online Service

In connection with your application for employment with J.T Barrier LLC (“Prospective Employer”), Prospective Employer, its employees, agents or contractors may obtain one or more reports regarding your driving, and safety inspection historyfrom 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 correctthis 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 J.T Barrier LLC (“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.

(2) AUTHORIZATION & GENERAL RELEASE
I hereby authorize J.T. Barrier LLC, and all of their agents (Driver IQ) to request and receive any information and records concerning me, including but not limited to consumer credit, criminal record history worker’s comp., driving, employment, military, civil and educational data and reports, from any individuals, corporations, partnerships, associations, institutions, schools, governmental agencies and departments, court, law enforcement and licensing agencies, consumer reporting agencies and other entities including my present and previous employers.

I further release and discharge J.T. Barrier LLC, all of their agents (Driver IQ) and all of its subsidiaries and affiliates, and every employee or agent of any of them, and all individuals and personal, business, private or public entities of any kind, from any and all claims and liability arising out of any request(s) for, receipt of, information or records pursuant to this authorization, or arising out of any compliance, or attempted compliance, with such request(s). I also authorize the procurement of any investigative consumer report and understand that it may contain information about my character, general reputation, personal characteristics, and mode of living whichever are applicable. I understand I have the right to make a written request within a reasonable period of time to Driver IQ for a complete and accurate disclosure of additional information concerning the nature and scope of the investigation. I further understand that the reporting of information by Driver IQ. Pursuant to the Fair Credit Reporting Act is not intended to authorize or condone a prospective employer’s request for and reliance upon information for purposes which are not legitimate under the Fair Credit Reporting Act or any federal or state employment laws. I acknowledge that I have voluntarily provided the above information for employment purposes, and I have carefully read and understand this authorization.