Driver Application Form

* Required Information

Date of Application *

Applicant Name *

IT IS LEIGHTON TRANSPORTATION SERVICES, INC POLICY TO PROVIDE EQUAL OPPORTUNITY WITH REGARD TO ALL TERMS AND CONDITIONS OF HIRING. THE COMPANY COMPLIES WITH FEDERAL AND STATE LAWS PROHIBITING DISCRIMINATION ON THE BASIS OF RACE, COLOR, RELIGION, SEX, NATIONAL ORIGIN, DISABILITY, VETERAN STATUS, AGE OR ANY OTHER PROTECTED CHARACTERISTIC. ANY DRIVER APPLICATION SUBMITTED TO LEIGHTON TRANSPORTATION SERVICES, INC.. / WHICH CONTAINS OMISSIONS, INCOMPLETE INFORMATION (IF NO SPECIFIC ANSWER, WRITE “NONE”), OR IS MISSING OTHER REQUIRED FORMS OR PAPERWORK WILL NOT BE REVIEWED. INCOMPLETE APPLICATIONS AND FORMS WILL BE RETURNED TO SENDER FOR COMPLETION.

THIS APPLICATION AND ALL INFORMATION SUBMITTED WITH THIS APPLICATION (INCLUDING COPIES OF DOCUMENTS) MUST BE CLEARLY LEGIBLE OR WILL BE RETURNED TO SENDER.

GENERAL INFORMATION

Current Street Address *

City *

State *

Zip Code *

How long at this address? *

Date of Birth *

Social Security Number *

Cell Number *

Home Number *

Driver Email *

LIST ADDRESSES FOR PREVIOUS THREE YEARS (ATTACH ADDITIONAL PAGES IF NEEDED)

Street Address

City

State

Zip Code

Street Address

City

State

Zip Code

Street Address

City

State

Zip Code

Emergency Contact Name

Address

Phone

Do you have the legal right to work in the US?

Yes

Have you ever been convicted of a Felony?

Yes

Explanation of Felony

LICENSE INFORMATION

State

License Number

Type

Expiration Date

Have you ever been denied a license, permit, or privilege to operate a motor vehicle?

Yes

If Yes, Please Explain

Has any License, permit, or privilege ever been suspended or revoked?

Yes

If Yes, Please Explain

PHYSICAL HISTORY (COPY OF YOUR CURRENT MEDICAL EXAMINATION AND MEDICAL CARD IS REQUIRED):

Have you been Granted a Waiver Under Section 391.49 of the FMCSA Regulations regarding Loss or Impairment of Limbs (a copy of the form is required)?

Yes

Date of your last D.O.T. Physical

CLASS OF EQUIPMENT

BOX TRUCK

Type of Equipment

Dates from

Dates to

Approximated Number of Miles

STRAIGHT TRUCK

Type of Equipment

Dates from

Dates to

Approximated Number of Miles

TRACTOR & SEMI-TRAILER

Type of Equipment

Dates from

Dates to

Approximated Number of Miles

OTHER

Type of Equipment

Dates from

Dates to

Approximated Number of Miles

DRIVER EXPERIENCE

Dates

Nature of Accident

Number of Fatalities

Number of Injuries

Penalty

Dates

Nature of Accident

Number of Fatalities

Number of Injuries

Penalty

Dates

Nature of Accident

Number of Fatalities

Number of Injuries

Penalty

ACCIDENT RECORD FOR THE PAST THREE (3) YEARS OR MORE (ATTACH MORE SHEETS IF NEEDED)

Choose a file

TRAFFIC CONVICTIONS AND FORFEITURES FOR THE PAST THREE (3) YEARS (OTHER THAN PARKING VIOLATIONS, ATTACH ADDITIONAL SHEET IF NEEDED)

Month / Year Convicted

Violation

State Violation Occured

Penalty

Month / Year Convicted

Violation

State Violation Occured

Penalty

Month / Year Convicted

Violation

State Violation Occured

Penalty

EMPLOYMENT HISTORY

CDL DRIVER APPLICANTS MUST PROVIDE TEN (10) YEARS OF EMPLOYMENT HISTORY. ADD ADDITIONAL EMPLOYMENT HISTORY PAGES, IF NEEDED. ANY GAPS IN EMPLOYMENT MUST BE EXPLAINED ON A SEPARATE PAGE AND INCLUDED WITH THIS APPLICATION. ALL INFORMATION OBTAINED FROM PREVIOUS EMPLOYERS / CARRIERS WILL BE KEPT CONFIDENTIAL. PLEASE LIST MOST RECENT EMPLOYER / CARRIER FIRST. INCLUDE COMPLETE ADDRESS INFORMATION STREET NUMBER AND NAME, CITY, STATE AND ZIP CODE.

CURRENT / LAST EMPLOYER:

Employer

Street Address

City

State

Zip Code

Contact

Phone

Fax

Position

From

Reason for Leaving

Was your Designated as a safety - sensitive function in any DOT - regulated mode subject to alcohol & controlled substances testing under 49 CFR part 40?

Yes

Where you subject to the federal motor carrier safety regulations (FMCSRs)?

Yes

PREVIOUS EMPLOYER:

Employer

Street Address

City

State

Zip Code

Contact

Phone

Fax

Position

From

Reason for Leaving

Was your Designated as a safety - sensitive function in any DOT - regulated mode subject to alcohol & controlled substances testing under 49 CFR part 40?

Yes

Where you subject to the federal motor carrier safety regulations (FMCSRs)?

Yes

PREVIOUS EMPLOYER:

Employer

Street Address

City

State

Zip Code

Contact

Phone

Fax

Position

From

Reason for Leaving

Was your Designated as a safety - sensitive function in any DOT - regulated mode subject to alcohol & controlled substances testing under 49 CFR part 40?

Yes

Where you subject to the federal motor carrier safety regulations (FMCSRs)?

Yes

PREVIOUS EMPLOYER:

Employer

Street Address

City

State

Zip Code

Contact

Phone

Fax

Position

From

Reason for Leaving

Was your Designated as a safety - sensitive function in any DOT - regulated mode subject to alcohol & controlled substances testing under 49 CFR part 40?

Yes

Where you subject to the federal motor carrier safety regulations (FMCSRs)?

Yes

APPLICANT: PLEASE READ AND SIGN BELOW:

I authorize you to make sure investigations and inquiries to my personal, employment, financial, or medical history and other related matters as may be necessary in arriving at an employment decision. I hereby release employers, schools, health care providers, and other persons from all liability in responding to inquiries and releasing information in connection with my application.
In the event of employment / work relationship, I understand that false or misleading information given in my applications or interview(s) may result in termination. I understand also, that I am required to abide by all rules and regulations of the Company.

“I understand that information I provide regarding current / previous employers may be used, and those employer(s) will be contacted, for the purpose of investigating my safety performance history as required by 49 CFR 391.23(d) and €. I understand that I have the right to:

Review information provided by current / previous employers (see note* below);
Have errors in the information corrected by previous and for those employers to re-send the corrected information to the prospective employer / carrier; and
Have a rebuttal statement attached to the alleged erroneous information, if the previous employer(s) and I cannot agree on the accuracy of the information.

Applicant Name

Date

*NOTE: Drivers who have had a previous DOT regulated employment history in the last three (3) years and wish to review previous employer-provided investigative information must submit a written request to the prospective employers / carrier. This may be done at any time, including when applying, or as late as thirty (30) days after being employed or being notified of denial of employment / work. Prospective employers / carriers must provide this information within five (5) days of receiving the written request. If Prospective employers / carriers have not yet received the requested information from the previous employer, then the five (5) day deadline will begin when the requested safety performance history information is received. If you have not arranged to pick up or receive the requested records within thirty (30) days of the Prospective employer / carrier making them available, the Prospective employer / carrier may consider you to have waived your request to review the record(s).

This certifies that I completed this application, and that all entries on it and information in it are true and complete to the best of my knowledge.

Applicant Name

Date

DRUG AND ALCOHOL TESTING RECORD REQUIRED QUESTIONS

In accordance with 49 CFR Part 40 Section 40.25 (i) of FMCSA regulations, please answer the following questions:

1. Have you ever tested positive on any pre-employment drug or alcohol test administered by an employer to which you applied for, but did not obtain, safety-sensitive transportation work covered by DOT agency drug and alcohol testing rules during the past 2 years?

Yes

2. Have you ever refused to test on any pre-employment drug or alcohol test administered by an employer which you applied for, but did not obtain, safety-sensitive transportation work covered by D.O.T agency drug and alcohol testing rules during the past 2 years?

Yes

3. If you answered YES to either of the above questions, you must be able to show documentation that you completed the Return-To-Duty process before you are allowed to perform any safety sensitive functions.

Date

Applicant Name

ACKNOWLEDGEMENT OF RECIEPT OF CONTROLLED SUBSTANCES AND ALCOHOL POLICY

I acknowledge that I have read, understand, and have accepted a copy of LEIGHTON TRANSPORTATION SERVICES, INC. Controlled Substances and Alcohol Policy.

I consent to submit to drug and alcohol screening and agree to comply with all of the requirements of the Federal Motor Carrier Safety Regulations, as well as all Federal, State, and Local Law, rules, or regulations.

I understand failure to adhere to the terms of this acknowledgment will result in my application being denied or my suspension as a qualified drive, and is grounds for my discharge or permanent cancellation of my lease.

Date

Applicant Name

DRUG WAIVER AND CONSENT FORM

This form must be completed and signed BEFORE the test and mailed with the physical form directly to the LEIGHTON TRANSPORTATION SERVICES, INC. Safety Department.

Applicant Name

Date of Birth

I hereby voluntarily authorize a physician or clinic authorized by LEIGHTON TRANSPORTATION SERVICES, INC. / Agent (please enter full Agent Name): , or LEIGHTON TRANSPORTATION SERVICES, INC. to take specimens of my urine to be tested for marijuana and / or controlled substances herein and further determine the content thereof. I understand and agree that the physician or clinic will disclose the results of the test to LEIGHTON TRANSPORTATION SERVICES, INC. and release any employees and / or agents thereof from any and all claims or causes resulting from the disclosure of the test results to the parties designated herein. I hereby further agree to waive any physician-patient privilege that may otherwise exist with the respect to the confidentiality of the test results.

I understand that this consent and release is subject to revocation at any time, except to the extent that action has taken in reliance hereon. In any event, this consent will remain in effect until revoked upon termination of employment / work relationship with LEIGHTON TRANSPORTATION SERVICES, INC. / Queeney Enterprise.

Applicant Name

Date

IMPORTANT DISCLOSURE REGARDING BACKGROUND REPORTS FROM THE PSP ONLINE SERVICE

In connection with your application for employment with LEIGHTON TRANSPORTATION SERVICES, INC. (“Prospective Employer”), Prospective Employer, its employees, agents or contractors may obtain one or more reports regarding your motor vehicle driving record, and safety inspection history from the Federal Motor Carrier Safety Administration (FMCSA).

When the application for employment is submitted in person, if Prospective Employer uses any information it obtains from the FMCSA in a decision not to hire you or to make any other adverse 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 action was based in part or whole on the 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 (3) business days of taking adverse action oral, written or electronic notification: that adverse action has been taken based in part on information it obtained from the FMCSA; the name, address, and a toll free number of FMCSA; that the FMCSA sis 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 what the FMCA 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 right under the Fair Credit Reporting Act.

Neither the Prospective Employee 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 Vehicles (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 the 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

I agree that the Prospective Employer may obtain such background reports, please read the following and sign before:

I authorize LEIGHTON TRANSPORTATION SERVICES, INC (Prospective Employer) to access the FMCSA Pre-Employment Screening (PSP) system to seek information regarding my commercial driving 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 understand that any crash or inspection in which I was involved will display on my PSP repot. 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.

Date

Applicant Name

NOTICE: THIS FORM IS MADE AVAILABLE TO MONTHLY ACCOUNT HOLDERS ON BEHALF OF THE U.S. DEPARTMENT OF TRANSPORTATION, FEDERAL MOTOR CARRIER SAFETY ADMINISTRATOR (FMCSA). ACCOUNT HOLDERS ARE REQUIRED BY FEDERAL LAW TO OBTAIN AN APPLICANT'S WRITTEN OR ELECTRONICA CONSENT PRIOR TO ACCESSING AND 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.

IMPORTANT DISCLOSURE REGARDING BACKGROUND REPORTS FROM THE PSP ONLINE SERVICE

The Prospective Employer cannot obtain background reports from FMCSA without your authorization.

AUTHORIZATION

I agree that the Prospective Employer may obtain such background reports, please read the following and sign before:

I authorize LEIGHTON TRANSPORTATION SERVICES, INC. (Prospective Employer) to access the FMCSA Pre-Employment Screening (PSP) system to seek information regarding my commercial driving 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.

Date

Name

PART I – DISCLOSURE AND AUTHORIZATION FOR RELEASE OF INFORMATION FOR EMPLOYMENT PURPOSES – 79 CFR PART 391.23, DOT DRUG AND ALCOHOL TESTING

In accordance with DOT Regulation 79 CFR Part 391.23 and 49 CFR part 40, each as applicable, I hereby authorize release of my DOT- regulated drug and alcohol testing records by the DOT – regulated employer(s) listed below. 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 alcohol concentration: (ii) verified positive drug tests; (iii) refusals to be tested (including adulterated and / or substituted test); (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 a return-to-duty process following a rule violation.

If any company listed below furnishes information concerning items (i) through (vi) above, I authorize such company to furnish the following information to LEIGHTON TRANSPORTATION SERVICES, INC. and if applicable: (i) dates of my negative drug and / or alcohol test and / or tests with results below 0.04 during the previous three (3) years; and (ii) the name and phone number of any substance abuse professional who evaluated me 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.

Previous DOT-Regulated Employer

City

State

Phone Number

Previous DOT-Regulated Employer

City

State

Phone Number

Previous DOT-Regulated Employer

City

State

Phone Number

By my signing below, I also certify the information I provide on and in connection with this form is true, accurate and complete. I agree that this form in original, faxed, photocopied or electronic (including electronically signed) form will be valid for any background checks that may be requested by or on behalf of the Customer.

Applicant Name

Social Security Number

Date

PART II – CONSUMER DISCLOSURE AND AUTHORIZATION FORM

Disclosure Regarding Background Investigation

The Company may request, for lawful employment purposes, background information about you from a consumer reporting agency in connection with your employment or application for employment (including independent contractor assignments, as applicable). This background information may be obtained in the form of consumer reports and / or investigative consumer reports (commonly known as “background reports”). An “investigative consumer report” is a background report that includes information from personal interviews (except in California, where that term includes background repots with or without information obtained from personal interviews), the most common form of which is checking person or professional references. These background reports may be obtained at any time after receipt of your authorization and, if you are hired or engaged by the Company, throughout your employment or your contract period, as allowed by law.

IIX Solutions or another consumer reporting agency, will prepare or assemble the background reports for the Company. IIX Solutions, Inc. is located and can be contacted by mail at information@iix.com, and can be contacted by phone at (800-683-8553. Information about IIX’s privacy practices is available at www.verisk.com/iix.

The background report may contain information concerning your character, general reputation, personal characteristics, mode of living, and credit standing. The types of information that may be obtained include, but are not limited to: social security number verifications, address history; credit reports and history; criminal records and history; public court records; driving records; accident history; worker’s compensation claims; bankruptcy filings; educational history verifications; (e.g., dates of attendance, degrees obtained); professional licensing and certification checks, drug / alcohol testing results, and drug / alcohol history in violation of the law and / or company policy; and other information bearing on your character, general reputation, personal characteristics, mode of living and credit standing.

This information may be abstained from private and public record sources, including, as appropriate: government agencies and courthouses; educational institutes; and former employers; and, for investigative consumer reports, personal interviews with sources such as neighbors, friends, former employers and associates; and other information sources. If the Company should obtain information bearing on your credit worthiness, credit standing or credit capacity for reasons other as required by law, then the Company will use such credit information to evaluate whether you would present an unacceptable risk of theft or other dishonest behavior in the job for which you are being evaluated.

You may request more information about the nature and scope of an investigative consumer report, if any, by contacting the Company.

A summary of your rights under the Fair Credit Reporting Act, as well as the FMCSA Notification of Driver Rights and certain state-specific notices, are provided.

Authorization of Background Investigation

I have carefully read and understand this Disclosure and Authorization form and the attached summery of rights under the Fair Credit Reporting Act. By my signature below, I consent to preparation of background reports to the Company and its designated representatives and agents, for the purpose of assisting the Company in making a determination as to my eligibility for employment (including independent contractor assignments, as applicable), promotion, and retention or for other lawful purposes. IO understand that id the Company hires me, without asking for my authorization again, throughout my employment or contract period from IIX Solutions, National Drug Screening, and Virginia DMV or other consumer reporting agencies.

I understand that information contained in my employment or contractor application, or otherwise disclosed by me before or during my employment or contract assignment, if any, may be used for the purpose of obtaining and evaluating background reports on me. I also understand that nothing contained herein shall be construed as an offer of employment or contract for services.

I hereby authorize the following, without limitation, to disclose information about me to the consumer reporting agency and its agents: law enforcement and all other federal, state and local agencies, learning institutions (including public and private schools, colleges and universities), testing agencies, information service bureaus, credit bureaus, recording / date repositories, courts ( federal, state and local), motor vehicle record agencies, my past or present employers, the military, and all other individuals and sources with any information about or concerning me. The information disclosed to the consumer reporting agency and its agents includes, but is not limited to, information concerning my employment and earning history, education, credit history, motor vehicle history, criminal history, military service, professional credentials and licenses.

By my signature below, I also certify the information I provided on and in connection with this form is true, accurate and complete. I agree that this form is original, faxed, photocopies or electronic (including electronically signed) form will be valid for any background reports that may be requested by or on behalf of the Company.

California, Minnesota or Oklahoma applicants only: Please check this box if you would like to receive (whenever you have such right under the applicable state law) a copy of your background report if one is obtained on you by the Company.

Last Name

First Name

Middle Name

Date

PAST EMPLOYMENT VERIFICATION

I authorize Leighton Transportation Services, Inc. and its agents or representatives the right to investigate all references and to secure additional information about my employment background. I hereby release from all liability for damages Leighton Transportation Services, Inc., its agents, or representatives for seeking such information and all other persons, corporations or organizations for furnishing such information:

Applicant Name

Social Security Number

Date of Birth

Date

Employer's Name

Phone Number

Address

Contact

Date of Employment

From

What type of position held?

If driver, see below

Type of Driving

Solo

Team

Type of Operation

Company Driver

Owner Operator

Drive for Owner Operator

Was It

Over the Road

Regional

Local

Type of Equipment

Tractor-Trailer	Straight Truck
Tri-Axle	Other

Other Type of Equipment

Other Type of Trailer

Trailer dimensions/capacity

Other Type of Commodities Hauled

Number of accidents/incidents while employed

Date

City/Town

State

Number of Injuries

Number of Fatalities

Hazmat Release

Yes

Vehicles Towed

Yes

Comments

Was your equipment returned to an authorized location

Yes

What was reason for leaving?

Voluntarily Quit

Layoff

Discharged

Why?

Is driver eligible for rehire?

Yes

Why?

Name

Title

Date

Address

Phone Number

IMPORTANT DISCLOSURE REGARDING BACKGROUND REPORTS FROM THE PSP Online Service

In connection with your application for employment with Leighton Transportation Services, Inc. (“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 Leighton Transportation Services, Inc. (“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.

Date

Name

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.

Drivers:

The following company policy will be applied to a 6-month time period. If a driver accumulates one or more of the following violations within a period of 6 months, the appropriate disciplinary action will be taken.

Major Violations:

Falsification of Logs
Driving over hours
Failure to submit logs in a timely manner (paper only)
Log violation(s) resulting in an Out of Service Order

1st Offense – *Verbal Warning (in written form so everything is clear).

2nd Offense – *Written Warning

3rd Offense – *Final Written Warning

4th Offense – Termination

*At any given time during the offenses a $50 fine (per major violation) may be assessed with the opportunity to have the charges waived if is completed by a specific deadline.

*Leighton Transportation Services, Inc. is a non-rehabilitating company. You will not be considered for employment or remain employed with our company if you fail a Past Employment, Pre-Employment, Random, Post-Accident, or Reasonable Suspicion drug and/or alcohol test. We have a NO TOLERANCE policy.

All questions or concerns can be brought to the attention of the Safety Department. All incidents are reviewed on a case-by-case basis and failure to comply with the guidelines will result in disciplinary action up to and including termination of employment.

I understand my individual responsibilities and will comply with the Leighton Transportation Services, Inc. Drug and Alcohol Policy.

Name

Date

Pneumatic	Van/Reefer
Dump	Tank
Flatbed	Other

Dry Bulk	Iron, Steel, Etc.
Coils	Machine
Gen. Freight	Produce
Liquid	Scrap
Other