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DRIVER APPLICATION PACKAGE CHECK LIST

It is very important to make sure the driver applicant completes all parts of the application package and signs and dates all required forms. Failing to do so will delay the hiring process.

Managers, use this check list to ensure the package is complete before submitting to Fleet Safety and Compliance.

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Robert Rodriguez408-748-3954 E-Mail rrodriguez@threeway.com

Shaunna Lenz650-245-3337 E-Mail slenz@threeway.com

DRIVER ELIGIBILITY REQUIREMENTS

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  • 8. No more than two traffic violation convictions, none of which are serious as defined by the FMCSR (see below) and one preventable accident within the past three years:

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DRIVER’S APPLICATION for EMPLOYMENT

In complianc with Federal and State equal employment opportunity laws, qualified applicants are considered for all postions without regard to race, color, religion, sex, national origin, age, marital status, or non-job related disability.
PLEASE PRINT NEATLY AND CLEARLY
Date of Application
Position(s) Applying:
Name:
Last Name
First Name
Middle Name
Social Security
List your addresses of residency for the past three years.
Current Address:
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Previous Addresses:
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Do you have the right to work in the United States?
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Date of Birth
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Can you provide proof of age?
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Have you ever worked for Three Way Logistics before ?
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Where?
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Rate of Pay
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Position
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Dates:

From:
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To:
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Reason for leaving
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Are you employed?
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If not, how long since leaving last employment?
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Who referred you?
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Rate of pay expected
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Have you been convicted of a felony or misdemeanor within the last 10 years?
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Is there any reason you might be unable to perform the functions of the job for which you have applied (as described in the attached job description)? If yes, explain if you wish.
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If yes, explain if you wish.
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EMPLOYMENT HISTORY

All driver applicants driving in interstate commerce must provide the following information on all employers during the preceding three years.

Application for driving a commercial motor vehicle (includes vehicles having a GVWR of 26,001 lbs. or more, vehicles designed to transport 15 or more passengers, or any size vehicle to transport hazardous materials in a quantity requiring placarding) in interstate or interstate commerce shall also provide an additional seven years’ information on those employers for whom the applicant operated such vehicle.

NOTE: List employers in reverse order starting with the most recent. Add another sheet if necessary.

EMPLOYER

Name:
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Address:
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City:
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State:
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Zip:
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Contact:
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Phone #:
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Date:

From
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To
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Position Held:
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Salary/Wage:
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Reason For Leaving:
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EMPLOYER

Name:
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Address:
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City:
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State:
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Zip:
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Contact:
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Phone#:
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Date:

From:
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To
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Position Held:
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Salary/Wage:
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Reason For Leaving:
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EMPLOYER

Name:
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Address:
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City:
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State:
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Zip:
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Contact:
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Phone #:
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Date:
From:
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To
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Position Held:
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Salary/Wage:
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Reason For Leaving:
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EMPLOYER

Name:
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Address:
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City:
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Sate:
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Zip:
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Contact:
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Phone #:
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Date:

From:
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To
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Position Held:
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Salary/Wage:
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Reason For Leaving:
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OTHER EXPERIENCE AND QUALIFICATIONS

List any trucking, transportation, or other experience that may help in your work for this company:
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List courses and training other than shown elsewhere in this application:
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List special equipment or technical materials you can work with (other than those already shown):
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TO BE READ AND SIGNED BY APPLICANT

This certifies 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.

I authorized you to make such investigations and inquiries of my personal, employment, financial, or medical history and other related matters as may be necessary in arriving at an employment decision. (Generally, inquiries regarding medical history will be made only if and after a conditional offer of employment has been extended.)

I hereby release employers, schools, healthcare providers and other persons from all liability in responding to inquiries and releasing information in connection with my application.

In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand also that I am required to abide by all rules and regulations of the Company.

Applicant’s Signature:
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Date:
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PROCESS RECORD

Applicant hired
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Rejected
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Date employed
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Base terminal
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Department
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Classification
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If rejected, a summary report of reasons should be placed in file.

 
ACCIDENT RECORD FOR PAST 5 YEARS
  Date Nature Of Accident Fatalities Injuries
Last accident
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Next previous
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TRAFFIC CONVICTIONS AND FORFEITURES FOR THE PAST 3 YEARS (Other than parking violations)

Location Date Charge Penalty
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Circle highest grade completed: 1 2 3 4 5 6 7 8
High School Grade:
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College Grade:
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Name of last school attended
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DRIVER EXPERIENCE AND QUALIFICATIONS

  State License # Type Expiration Date
Driver Licenses
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Have you ever been denied a license, permit, or privilege to operate a motor vehicle?
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Has any license, permit or privilege ever been suspended or revoked?
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If yes, to either one or two, attach a statement giving details.

Class Of Equipment TYPE OF EQUIPMENT
(Van, Tank, Flat, Etc.)
Dates
From
To
APPROXIMATE # MILES
Straight Truck
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Tractor & Semi-Trailer
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Tractor-Two Trailers
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List states operated in the last 5 years
Any safe driving awards and with whom?
 
Motor Vehicle Driver’s

CERTIFICATION of COMPLIANCE with
DRIVER LICENSE REQUIREMENTS

MOTOR CARRIER INSTRUCTIONS: The requirements in Part 383 apply to every driver who operates in intrastate, interstate, or foreign commerce and operates a vehicle weighing or rated at 26,001 pounds or more, can transport more than 15 people, or transports hazardous materials that require placarding.

The requirements in Part 391 apply to every driver who operates in interstate commerce and operates a vehicle weighing or rated at 10,001 pounds or more, can transport more than 15 people (or more than 8 people when there is direct compensation), or transports hazardous materials that require placarding.

DRIVER REQUIREMENTS: Parts 383 and 391 of the Federal Motor Carrier Safety Regulations contain certain driver licensing requirements that you as a driver must comply with, including the following:

  • 1) POSSESS ONLY ONE LICENSE: You, as a commercial vehicle driver, may not possess more than one motor vehicle operator’s license.
  • 2) NOTIFICATION OF LICENSE SUSPENSION, REVOCATION, OR CANCELLATION: Sections 391.15(b) and 383.33 of the Federal Motor Carrier Safety Regulations require that you notify your employer the NEXT BUSINESS DAY of any revocation, suspension, cancellation, or disqualification of your driver’s license or driving privilege. In addition, Section 383.31 requires that any time you are convicted of violating a state or local traffic law (other than parking); you must report it within 30 days to your employing motor carrier. The notification must be in writing.
  • 3)CDL DOMICILE REQUIREMENT: Section 383.23(a)(2) requires that your commercial driver’s license be issued by your legal state of domicile, where you have your true, fixed, and permanent home and principal residence and to which you have the intention of returning whenever you are absent. If you establish a new domicile in another state, you must apply to transfer your CDL within 30 days.
The following license is the only one I possess:

Driver’s license number
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State
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Exp. Date
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DRIVER’S CERTIFICATION: I certify that I have read and understood the above requirements.

Driver’s name (Please print):
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Driver’s signature:
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Date
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Note:
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MOTOR VECHICLE DRIVER’S CERTIFICATION OF VIOLATIONS/ ANNUAL REVIEW OF DRIVING RECORD

MOTOR CARRIER INSTRUCTIONS: Each motor carrier shall at least once every 12 months, require each driver it employs to prepare and furnish it with a list of all violations of motor vehicle traffic laws and ordinances (other than violations involving only parking) of which the driver has been convicted, or on account of which he/she has forfeited bond or collateral during the preceding 12 months (Section 391.27). Drivers who have provided information required by Section 383.31 need not repeat that information on this form.

DRIVER REQUIREMENTS: Each driver shall furnish the list as required by the motor carrier above. If the driver has not been convicted of, or forfeited bond or collateral on account of any violation which must be listed, he/she shall so certify (Section 391.27).

COMPLETED BY DRIVER – CERTIFICATION OF VIOLATIONS

Name of Driver (Print)
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Home Terminal (City & State)
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Social Security #:
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Driver’s License #:
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State
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Exp. Date
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I certify that the following is a true and complete list of traffic violations required to be listed (other than those I have provided under Part 383) for which I have been convicted or forfeited bond or collateral during the past 12 months.

If you have had no violations, check the following box :

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DATE OFFENSE LOCATION TYPE OF VEHICLE OPERATED
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If no violations are listed above, I certify that I have not been convicted or forfeited bond or collateral on account of any violation (other than those I provided under Part 383) required to be listed during the past 12 months.

Date of Certification
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DriverSignature:
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COMPLETED BY MOTOR CARRIER – ANNUAL REVIEW OF DRIVING RECORD

MOTOR CARRIER INSTRUCTIONS: Review the Certification of Violations listed above and other information described

in Section 391.25 of the Federal Motor Safety Regulations. Complete the information requested below:

I have hereby reviewed the driving record of the above named driver in accordance with Section 391.25 and find that he/she:

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Action taken with driver:
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Reviewed by:

Signature
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Printed Name
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Date
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Title
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Three Way Logistics inc. dba Three Way 42505 Christy Street, Fremont, CA 94538

Maintain this document in the driver’s qualification file. This document may be purged after 3 years from date of execution.
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PREVIOUS PRE-EMPLOYMENT EMPLOYEE ALCOHOL AND DRUG TEST STATEMENT

Sec.40.25(j) As the employer, you must also ask the employee 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 employee admits that he or she had a positive test or refusal to test, you must not use the employee to perform safety-sensitive functions for you, until and unless the employee documents successful completion of the return-to-duty process. (See Sec.4025(b)(5) and (e))

Company Name:
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Street Address:
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City:
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State
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Zip
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Prospective Employee Name
(please print):
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ID Number
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The prospective employee is required by Sec.40.25 (j) to respond to the following questions:

1. Have you tested positive, or refused to test, on any 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 two years?

Check one:
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2. If you answered yes, can you provide/obtain proof that you have successfully completed the DOT return-to-duty requirements?

Check one:
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Prospective Employee Signature:
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Date
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Witnessed By (Signature):
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Date
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PRE-EMPLOYMENT URINALYSIS CONSENT FORM

I understand that as required by the Federal Motor Carrier Safety Regulations, Title 49 Code of Federal Regulations, Section 382.301, all driver –applicants of this company must be tested for controlled substances as a pre-condition for employment.

I consent to the urine sample collection and testing for controlled substances.

I understand that a positive test result for controlled substances will render me unqualified to operate a commercial motor vehicle.

The medical review officer will maintain the results of my test. Negative and positive results will be reported to the company. If the results are positive, the controlled substances will be identified. The results will not be released to any other parties without my written authorization.

I understand the above conditions and hereby agree to comply with them.

Signature
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Date
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Printed Name
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EMPLOYER PULL NOTICE PROGRAM

AUTHORIZATION FOR RELEASE OF DRIVER RECORD INFORMATION

I,
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, California Driver License Number,
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hereby authorize the California Department of Motor Vehicles (DMV) to disclose or otherwise make available, my driving record, to my employer,_
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I understand that my employer may enroll me in the Employer Pull Notice (EPN) program to receive a driver record report at least once every twelve (12) months or when any subsequent conviction, failure to appear, accident, driver’s license suspension, revocation, or any other action is taken against my driving privilege during my employment.

I am not driving in a capacity that requires mandatory enrollment in the EPN program pursuant to California Vehicle Code (CVC) Section 1808.1(k). I understand that enrollment in the EPN program is in an effort to promote driver safety, and that my driver license report will be released to my employer to determine my eligibility as a licensed driver for my employment.

EXECUTED AT: CITY
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COUNTY
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STATE
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DATE
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SIGNATURE OF EMPLOYEE
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I,
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, of
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do hereby certify under penalty of perjury under the laws in the State of California, that I am an authorized representative of this company, that the information entered on this document is true and correct, to the best of my knowledge and that I am requesting driver record information on the above individual to verify the information as provided by said individual. This record is to be used by this employer in the normal course of business and as a legitimate business need to verify information relating to a driving position not mandated pursuant to CVC Section 1808.1. The information received will not be used for any unlawful purpose. I understand that if I have provided false information, I may be subject to prosecution for perjury (Penal Code Section 118) and false representation (CVC Section 1808.45). These are punishable by a fine not exceeding five thousand dollars ($5,000) or by imprisonment in the county jail not exceeding one year, or both fine and imprisonment. I understand and acknowledge that any failure to maintain confidentiality is both civilly and criminally punishable pursuant to CVC Sections 1808.45 and 1808.46.

EXECUTED AT: CITY
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COUNTY
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STATE
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Date
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SIGNATURE AND TITLE OF AUTHORIZED REPRESENTATIVE

To obtain a driver record on a prospective employee you may submit an INF 1119 form. To add this driver to the EPN Program you must submit the applicable forms: INF 1100, INF 1102, INF 1103, INF 1103A form. You may obtain forms at our website at www.dmv.ca.gov/otherservices, or by calling 916-657-6346.

THIS FORM MUST BE COMPLETED AND RETAINED AT THE EMPLOYER’S PRINCIPAL PLACE OF BUSINESS AND MADE AVAILABLE UPON REQUEST TO DMV STAFF

DO NOT RETURN THIS FORM TO DMV.

 

DISCLOSURE AND RELEASE

In connection with my application for employment (including contract for services) with Triple Play Services Inc. (“Employer”), I understand that consumer reports, which may contain public record information, may be requested from a consumer reporting agency. These reports may include the following types of information: names and dates of previous employers, reason for termination of employment, work experience, accidents, etc. I further understand that such reports may contain public record information concerning my driving record, workers’ compensation claims, credit, bankruptcy proceedings, criminal records, etc., from federal, state and other agencies, which maintain such records; as well as information from the agency concerning previous driving record requests made by others from such state agencies, and state provided driving records.

I AUTHORIZE, WITHOUT RESERVATION, ANY PARTY OR AGENCY CONTACTED BY THE CONSUMER REPORTING AGENCY TO FURNISH THE ABOVE-MENTIONED INFORMATION.

I have the right to make a request to Applicant Information, a consumer reporting agency (which Employer will identify to me prior to taking adverse action based in whole or in part upon information contained in such report), upon proper identification, to request the nature and substance of all information in its files on me at the time of my request, including the sources of information; and the recipients of any reports on me which the agency has previously furnished within the two year period preceding my request. I hereby consent to your obtaining the above information from the agency; and I agree that such information which the agency has or obtains, and my employment history with you if I am hired, may be supplied by Employer to the agency for release to other companies which subscribe to the agency’s services.

I hereby authorize procurement of consumer report(s). If hired (or contracted), this authorization shall remain on file and shall serve as ongoing authorization for you to procure consumer reports at any time during my employment (or contract) period.

  • California, Minnesota, and Oklahoma Applicants only: Check box if you request a copy of any consumer report ordered by you.

For consumers applying for work in New York: I acknowledge receiving a copy of Article 23-A of the New York Correction Law (Initials)

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Print Name
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Social Security No.
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Applicant’s Signature
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Date of birth
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Current Street Address
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Driver’s License
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D/L State
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City
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State
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Zip
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Telephone Number
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Date
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Corporate

Phone: 408.748.3929 Fax: 408.748.3970 ClientSolutions@threeway.com

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