Driver Candidate Questionaire
What are your expectations of Dutch Maid: (Mileage, Home Time, Goals (short term, long term, etc.)
What should Dutch Maid expect from you: (Attitude, flexability, honesty, etc.)
Pursuant to changes to Part 40 of the Federal Motor Carrier Safety Regulations, this Addendum to the Driver's application for employment must be completed by each applicant.
Have you, the applicant tested positive or refuse to be tested 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 the DOT agency drug and alcohol Testing rules during the past two years.
If your answer to the above question is yes, please list the motor carrier(s) you applied to below:
Name of Motor Carrier:
In addition, if the answer to the above question is yes, please list the name and number of the Substance Abuse Profressional who managed your evaluation:
Name of SAP:
In connection with my preliminary application for employment with Dutch Maid Logistics Inc., I understand that a report which may contain public record information is being requested from various sources. This report may include the following types of information: names and dates of previous employment, reasons for termination, alcohol tests with a concentration result of 0.04 or greater, controlled substance testing, refusals of applicant to test, work experience, accidents, etc. I further understand that such report may contain public record information concerning my driving record, credit, bankruptcy proceedings, etc. from Federal, state and other agencies which maintain such records as well as information concerning previous driving requests made by others for such agencies; state provided driving record and claims involving me in the files of insurance companies. I hereby authorize, without reservation, any party or agency contacted by Dutch Maid Logistics Inc. or its authorized representatives to furnish the above mentioned information without fear of reprisal, accordingly those furnishing such information are hereby released from any and all liabilities which result from furnishing such information. I have the right to make a request, upon proper identification, to request the nature and substance of all information from Dutch Maid Logistics Inc., at the time of my request and the sources of information. I hereby authorize to Dutch Maid Logistics Inc., obtaining the above information.
By checking this box, I acknowledge that I have read and understand the above Important Notice of Rights and also have been given the opportunity to copy/print the notice.
Download/View the notice.
Prospective Employer: Dutch Maid Logistics Inc. 3377 St. Rt. 224 Willard, OH 44890
MANDATORY USE FOR ALL ACCOUNT HOLDERS IMPORTANT NOTICE REGARDING BACKGROUND REPORTS FROM THE PSP Online Service
1. In connection with your application for employment with Dutch Maid Logistics, 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.
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:
2. I authorize Dutch Maid Logistics, 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 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.
By checking this box, I acknowledge that I have read and understand the above Important Noticeof Rights and also have been given the opportunity to copy/print the notice.
Download/View the notice.
NOTICE: This form is made available to monthly account holders by NICT 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 provided in paragraphs 1-4 of this document to obtain an Applicant’s consent. The language must be used in whole, exactly as provided. The language may be included with other consent forms or language at the discretion of the account holder, provided the four paragraphs remain intact and the language is unchanged. LAST UPDATED 10/29/2012
(Please read carefully before submitting)
In connection with my application for employment with you, I understand that an investigative consumer report is being requested from DAC Services, Tulsa, Oklahoma, that will include information as to my character, work habits, performance and experience, along with reasons for termination of past employment obtained from previous employers. Further, I understand that you will be requesting information concerning my driving record and/or information from various state agencies which maintain records concerning traffic offenses, accidents, etc., as well as information from DAC concerning (1) previous driving record requests made by others from such state agencies and (2) claims involving me in the files of insurance companies. I have the right to make a written request within a reasonable period of time to receive additional detailed information about the nature and scope of this investigation. I hereby consent to your obtaining the above-described information from DAC, and agree that such information which DAC has or obtains, and my employment history with you if I am hired, will be supplied by DAC to other companies which subscribe to DAC's services.
IF HIRED BY YOU, I FURTHER CONSENT TO YOUR FURNISHING TO DAC INFORMATION CONCERNING MY CHARACTER, WORK HABITS, PERFORMANCE, DRIVING RECORD AND EXPERIENCE, AS WELL AS ANY REASONS FOR TERMINATION OF MY EMPLOYMENT, AND FURTHER CONSENT TO DAC'S FURNISHING SUCH INFORMATION IN THE FUTURE TO OTHER COMPANIES WHICH SUBSCRIBE TO DAC'S SERVICES FROM WHICH I MAY BE SEEKING EMPLOYMENT, AND TO INSURANCE COMPANIES OR THEIR AGENTS IN CONNECTION WITH ISSUANCE OR MAINTENANCE OF INSURANCE COVERAGE.
I understand that DUTCH MAID Produce, Inc. or its agents may investigate my background to ascertain any and all information of concern as to my record, whether same is on record or not, and I hereby release employers and persons named herein of all liability for any damages on account of the furnishing of such information.
I hereby authorized the release of any requested information relative to my driving record, past employment, character, or other information requested by or from DUTCH MAID Produce, Inc. I hereby release all parties concerned for all liability for any damages on account of the furnishing of such information.
If requested to do so, I agree to submit to psychological and/or physical testing. I also agree to submit to urine, breath or blood analysis for illegal drugs and/or alcohol.
It is agreed and understood that any misrepresentations of information given shall be considered an act of dishonesty and, if employed, may result in my dismissal.
I understand that acceptance of an offer of employment does not create a contractual obligation upon DUTCH MAID Produce, Inc. to continue to employ me in the future.
This application from employment shall be considered active for a period not to exceed 90 days.
I CERTIFY THAT I AM SOLELY APPLYING FOR THIS POSITION FOR PERSONAL GAIN AND THAT ALL THE INFORMATION CONTAINED THEREIN IS FACTUAL.
I hereby certify that this application was completed by me, and that all entries on it and information in it are true and complete to the best of my knowledge.