Authorization Forms


 

Trucking Industry:

DOT D/A Disclosure and Authorizations


 
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PART I: Disclosure and Authorization For Release of Information For Employment Purposes - 49 CFR 391.23, DOT Drug and Alcohol Testing
In accordance with DOT Regulation 49 CFR Part 391.23, I hereby release of my DOT-regulated drug and alcohol testing records by the DOT-regulated employer(s) listed below to USIS for the purpose of USIS transmitting such records to the USIS customer(s) listed above. I understand that information/documents released pursuant to this Part I is limited to the following DOT-regulated testing items, including pre-employment testing results, occurring during the previous three (3) years: (i) alcohol tests with a result of 0.04 or higher; (ii) verified positive drug tests; (iii) refusals to be tested (including adulterated and/or substituted tests); (iv) other violations of DOT drug and alcohol testing regulations (i.e., violations of 49 CFR 382 Subpart B); (v) information obtained from previous employers of a drug and alcohol rule violation; and (vi) any documentation of completion of the return-to-duty process following a rule violation. If any company listed below furnished USIS with information concerning items (i) through (vi) above, I also authorize such company to furnish the following information to USIS, if applicable: (i) dates of my negative drug and/or alcohol tests and/or tests with results below 0.04 during the previous three (3) years.
List all DOT-regulated employers you have applied with and/or worked for in a safety-sensitive function during the previous three (3) years. If necessary, attach additional pages, including the date, your name, social security number and signature.
By signing below, I certify that; (i) all information provided herein is complete and accurate; (ii) I have read and fully understand the Part I disclosure and authorization for release; (iii) prior to signing I was given an opportunity to ask questions and to have those questions answered to my satisfaction; (iv) I execute this authorization voluntarily and with the knowledge that the information obtained pursuant to this authorization could affect my eligibility for employment, promotion, retention or other purpose; (v) I understand I may review this document with legal counsel prior to signing; and (vi) facsimile or photographic copies of the authorization are a valid as an original
Date of Birth: *
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PART II: Consumer Report and Investigative Consumer Report Disclosure (For Employment Purposes)
In connection with your employment or application for employment (including contract for services) and in accordance with applicable laws, USIS may obtain or assemble consumer reports and/or investigative consumer reports (collectively, "Reports") which may include information about you related to: previous employment (including employers, dates of employment, salary information, reasons for termination, etc.) accident history, academic history, verification of references and other information supplied by applicant, professional credentials, drug/alcohol use in violation of law and/or company policy, driving record, workers' compensation claims, credit history, credit worthiness, credit capacity, bankruptcy fillings, criminal history records, information about your character, general reputation, personal characteristics and mode of living (collectively, "Information"). Information may be obtained from government agencies, educational institutions, USIS clients, personal references, personal interviews and other information suppliers (collectively "Suppliers"). Upon providing proper identification and complying with any applicable legal requirements, you have the right to request the nature and substance of all Information in USIS;s file pertaining to you at the time of your request, including but not limited to: (i) whether any Reports have been provided by USIS to other parties; (ii) identification of any Suppliers utilized by USIS in compiling such Reports; and (iii) identification of any recipients of Reports furnished by USIS within the two (2) year period preceding your request. USIS may be contacted by mail at P.O. Box 33181, Tulsa, OK, 74153, or by phone at (800) 381-0645.
Check here if you are applying for employment in California and/or you are a California resident and, in either case, you wish to receive a copy of your credit report or investigative consumer report if one is obtained or assembled by USIS. Pursuant to the California Civil Code, you may view the file maintained on you by USIS during normal business hours. You may also obtain a copy of this file by submitting proper identification and paying applicable costs for such file, if required by law, by contacting USIS in person or by mail. USIS is required to have personnel available to explain your file to you and must explain to you any coded information appearing in you file. If you appear in person, a person of your choice may accompany you, provided that this person furnishes proper identification.
Check here if you are applying for employment in Oklahoma and/or you are an Oklahoma resident and, in either case, you wish to receive a copy of your consumer report if one is obtained or assembled by USIS.
Check here if you are applying for employment in Minnesota and/or you are a Minnesota resident and, in either case, you wish to receive a copy of your consumer report if one is obtained or assembled by USIS.
PART II: Authorization For Release on Information (For Employment).
I hereby authorize USIS to receive information and disclose such information to its customers for the purpose of making a determination as to my eligibility for employment, promotion, retention or other lawful purpose. If hires or contracted, I authorize USIS and the USIS customer named above ("Customer") to retain this document on file to act as ongoing authorization for the procurement and possession of Reports at any time during my employment or contract period. I fully release USIS and Suppliers from all claims of damages related to the investigation of my background and provision of information as set forth in this disclosure and authorization. I agree that information in USIS's possession and my employment history with Customer if I am hired, may be supplied by USIS to other USIS customers for legally permissible purposes; provided, such information will not include the Drug and Alcohol information set forth in Part I above, unless I have given a separate specific consent for USIS to share such information. By signing below, I certify that: (i) all information provided herein is complete and accurate; (ii) I have read and fully understand this Part II disclosure and authorization for release; (iii) prior to signing I was given an opportunity to ask questions and to have those questions answered to my satisfaction; (iv) I execute this authorization voluntarily and with the knowledge that the information obtained pursuant to this authorization could affect my eligibility for employment, promotion, retention or other lawful purpose; (v) I understand I may review this document with legal counsel prior to signing; (vi) I authorize USIS and any person or entity contacted by USIS to furnish the above mentioned information; and (vii) facsimile or photographic copies of the authorization are as valid as an original.
NOTE: THIS AUTHORIZATION DOES NOT APPLY TO DRUG & ALCOHOL INFO. ADDRESSED IN PART 1.
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MANDATORY USE FOR ALL MONTHLY ACCOUNT HOLDERS - Important Notice Regarding Background Reports From The PSP Online Service
(Prospective Employer)
it 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. The Prospective Employer cannot obtain background reports from FMCSA unless you consent in writing. If you agree that the Prospective Employer may obtain such background reports, please read the following and sign below:
(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 consenting to 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.
3.) 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 am challenging 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.
4.) Please note: 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 FMCSR violations that have been adjudicated by a court of law will also appear, and remain, on a PSP report.
I have read the above Notice Regarding Background Reports provided to me by Prospective Employer and I understand that if I sign this consent form, 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.
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