Test

Applicant

First Middle Last

Present Address

Street City - Municipality State Zip

How Long

Maiden Name and/or Alias(s)

Municipality of Residence

(Borough, Township, etc) County

Phone

Cell Phone

Email Address

Please provide ALL previous addresses that you resided at since adulthood.

Previous Address

Previous Address	How Long	Actions

There are no Entries.

Add additional sheets with previous addresses as needed.

Place of Birth

Date Of Birth

Are you legally eligible for employment in the U.S.?

Yes

No

Are You U.S Citezen?

Yes

No

Spouse's Name

Cell Phone

Employment History

List your last employers over the past 10 years, including military service. Indicate any periods of unemployment.

Employment History

Employer's Name	Address	Telephone Number	Reason For Leaving	Position	Salary/ Wages:	Dates	Describe the work you did	Actions

There are no Entries.

Periods of Unemployment

List

From

To

Education

Name Of Schools	State	Years Completed/Credits	Did You Graduate?	Degree/Course of Study	Actions

There are no Entries.

Criminal History

Have you ever been charged with any act of dishonesty?

Yes

No

If Yes Explain

Have you ever been disciplined by an employer for an act of dishonesty?

Yes

No

If Yes Explain

List ALL felony and misdemeanor convictions.

If none, indicate "NONE" under Conviction Offense below.

Conviction Offence

Date	Conviction Offense	Type	Penalty	Actions

There are no Entries.

List ALL charges.

If none, indicate “NONE” under Pending Charges below.

Pending Charges

Dated Charged	Pending Charges	Status	Actions

There are no Entries.

Driving License Information

Current

Operator Number

State

Restrictions / Class

Expiration Date

State

Restrictions / Class

Expiration Date

Do you have a Commercial Driver's License?

Yes

No

If CDL, class

Endorsements

Have you ever been denied a driver's license or pemit?

yes

No

If yes need explain :

Have you ever had your driver's license revoked or suspended?

Yes

No

If yes, explain:

Driving Experience

Vehicle Type	Description of Vehicle	Dates	Company Name	Number of Miles	Actions

There are no Entries.

Driving Record

Have you ever been convicted of Driving Under the Influence?

Yes

No

When and Explain Circumstances

Have you ever been convicted of refusing to submit to an alcohol or other type of sobriety Test?

Yes

No

If yes explain

List all Traffic Convictions including DUI for the last Ten (10) years. If none, place “NONE” under date below.

Traffic Convictions

Date	Vehicle Type	Boro/City	Charge	Penalty	Actions

There are no Entries.

Due you have any Pending Traffic Violations ?

Yes

No

If Yes Explain

Accident Record

If none, write “NONE” below under Description of Accident.

Accident Record

Date	Description of Accident	Injuries / Damage	Actions

There are no Entries.

Emergency Conact

Name and Relationship (ie spouse, parent, friend, etc.)

Phone Number

To Be Read and Signed by Applicant

It is agreed and understood that any misrepresentation or omissions of information given on this application shall be considered an act of dishonesty.

It is agreed and understood that the Eaborn Truck Service Inc. d/b/a Eaborn Trucking or its agents may investigate the applicant by contacting anyone it determines necessary to determine the accuracy and completeness of the information on the application and any additional information received from conducting a background and reference checks. The applicant releases Eaborn Truck Service, Inc. d/b/a Eaborn Trucking and its employees, Officers, and agents from all liability or damages in obtaining information about the applicant.

The applicant agrees to furnish such additional information and complete such examinations as may be required to complete the applicant's file or is statutorily required.

By signing the application, I certify that the application was completed by me and that all entries and information are complete and true to the best of my knowledge.

Applicant Signature

Date

Social Security Number

Verify All Information is Completed

Please indicate any additional comments/experiences or information that would be helpful in understanding your abilities. Also, please explain your reason for seeking new employment.

General Consent for Limited Queries of the Federal Motor Carrier Safety Administration (FMCSA) Drug and Alcohol Clearinghouse

Driver Name

Employee Signature

Date

Important disclosure regarding background reports from the PSP online service

In connection with your application for employment with Eaborn Trucking, 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 ofthe 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. Ifyou 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

I authorize Eaborn Trucking, 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

Signature

Name (Please Print)

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.

Para información en español, visite www.consumerfinance.gov/learnmore o escribe a la Consumer Financial Protection Bureau, 1700 G Street N. W., Washington, DC 20552.

A Summary of Your Rights Under the Fair Credit Reporting Act

The federal Fair Credit Reporting Act (FCRA) promotes the accuracy, fairness, and privacy of information in the files of consumer reporting agencies. There are many types of consumer reporting agencies, including credit bureaus and specialty agencies (such as agencies that sell information about check writing histories, medical records, and rental history records). Here is a summary of your major rights under the FCRA. For more information, including information about additional rights, go to www.consumerfinance.gov/learnmore/ or write to: Consumer Financial Protection Bureau, 1700 G Street N.W., Washington, DC 20552.

You must be told if information in your file has been used against you. Anyone who uses a credit report or another type of consumer report to deny your application for credit, insurance, or employment - or to take another adverse action against you - must tell you, and must give you the name, address, and phone number of the agency that provided the information.
You have the right to know what is in your file. You may request and obtain all the information about you in the files of a consumer reporting agency (your "file disclosure"). You will be required to provide proper identification, which may include your Social Security number. In many cases, the disclosure will be free. You are entitled to a free file disclosure if:

a person has taken adverse action against you because of information in your credit report.
you are the victim of identity theft and place a fraud alert in your file.
your file contains inaccurate information as a result of fraud.
you are on public assistance.
you are unemployed but expect to apply for employment within 60 days.

In addition, all consumers are entitled to one free disclosure every 12 months upon request from each nationwide credit bureau and from nationwide specialty consumer reporting agencies. See https:/www.consumerfinance.gov/learnmore/ for additional information.
You have the right to ask for a credit score. Credit scores are numerical summaries of your credit-worthiness based on information from credit bureaus. You may request a credit score from consumer reporting agencies that create scores or distribute scores used in residential real property loans, but you will have to pay for it. In some mortgage transactions, you will receive credit score information for free from the mortgage lender.
You have the right to dispute incomplete or inaccurate information. If you identify information in your file that is incomplete or inaccurate, and report it to the consumer reporting agency, the agency must investigate unless your dispute is frivolous. See https:/www.consumerfinance.gov/learnmore/ for an explanation of dispute procedures.
Consumer reporting agencies must correct or delete inaccurate, incomplete, or unverifiable information. Inaccurate, incomplete, or unverifiable information must be removed or corrected, usually within 30 days. However, a consumer reporting agency may continue to report information it has verified as accurate.
Consumer reporting agencies may not report outdated negative information. In most cases, a consumer reporting agency may not report negative information that is more than seven years old, or bankruptcies that are more than 10 years old.
Access to your file is limited. A'consumer reporting agency may provide information about you only to people with a valid need -- usually to consider an application with a creditor, insurer, employer, landlord, or other business. The FCRA specifies those with a valid'need for access.
You must give your consent for reports to be provided to employers. A consumer reporting agency may not give out information about you to your employer, or a potential employer, without your written consent given to the employer. Written consent generally is not required in the trucking industry. For more information, go to www.consumerfinance.gov/learnmore.
You many limit "prescreened" offers of credit and insurance you get based on information in your credit report. Unsolicited "prescreened" offers for credit and insurance must include a toll-free phone number you can call if you choose to remove your name and address from the lists these offers are based on. You may opt out with the nationwide credit bureaus at 1-888-5-OPTOUT (1-888-567-8688).
You may seek damages from violators. If a consumer reporting agency, or, in some cases, a user of consumer reports or a furnisher of information to a consumer reporting agencу violates the FCRA, you may be able to sue in state or federal court.
Identity theft victims and active duty military personnel have additional rights. For more information, visit www.consumerfinance.gov/learnmore.

TYPE OF BUSINESS:	CONTAСТ:
1.a. Banks, savings associations, and credit unions with total assets of over $10 billion and their affiliates	a. Consumer Financial Protection Bureau 1700 G Street, N.W. Washington, DC 20552
b. Such affiliates that are not banks, savings associations, or credit unions also should list, in addition to the CFPB:	b. Federal Trade Commission: Consumer Response Center - FCRA Washington, DC 20580 (877) 382-4357
2. To the extent not included in item 1 above:
a. National banks, federal savings associations, and federal brancheş and federal agencies of foreign banks	a. Office of the Comptroller of the Currency Customer Assistance Group 1301 McKinney Street, Suite 3450 Houston, TX 77010-9050
b. State member banks, branches and agencies of foreign banks (other than federal branches, federal agencies, and Insured State Branches of Foreign Banks), commercial lending companies owned or controlled by foreign banks, and organizations operating under section 25 or 25A of the Federal Reserve Act	b. Federal Reserve Consumer Help Center P.O. Box. 1200 Minneapolis, MN 55480
c. Nonmember Insured Banks, Insured State Branches of Foreign Banks, and insured state savings associations	c. FDIC Consumer Response Center 1100 Walnut Street, Box #11 Kansas City, MO 64106
d. Federal Credit Unions	d. National Credit Union Administration Office of Consumer Protection (ОCP) Division of Consumer Compliance and Outreach (DCCO) 1775 Duke Street Alexandria, VA 22314
3. Air carriers	Asst. General Counsel for Aviation Enforcement & Proceedings Aviation Consumer Protection Division Department of Transportation 1200 New Jersey Avenue, S.E. Washington, DC 20590
4. Creditors Subject to the Surface Transportation Board	Office of Proceedings, Surface Transportation Board Department of Transportation 395 E Street, S.W. Washington, DC 20423
5. Creditors Subject to the Packers and Stockyards Act, 1921	Nearest Packers and Stockyards Administration area supervisor
6. Small Business Investment Companies	Associate Deputy Administrator for Capital Access United States Small Business Administration 409 Third Street, S.W., 8th Floor Washington, DC 20416
7. Brokers and Dealers	Securities and Exchange Commission 100 F Street, N.E. Washington, DC 20549
8. Federal Land Banks, Federal Land Bank Associations, Federal Intermediate Credit Banks, and Production Credit Associations	Farm Credit Administration 1501 Farm Credit Drive McLean, VA 22102-5090
9. Retailers, Finance Companies, and All Other Creditors Not Listed Above	FTC Regional Office for region in which the creditor operates or Federal Trade Commission: Consumer Response Center - FCRA Washington, DC 20580 (877) 382-4357

Call Today: (412) 921-9928

Employment Application

Employment History

Periods of Unemployment

Education

Criminal History

Physical History

Driving License Information

Driving Experience

Driving Record

Accident Record

Emergency Conact

To Be Read and Signed by Applicant

Verify All Information is Completed

General Consent for Limited Queries of the Federal Motor Carrier Safety Administration (FMCSA) Drug and Alcohol Clearinghouse

Important disclosure regarding background reports from the PSP online service

Authorization

A Summary of Your Rights Under the Fair Credit Reporting Act

CONTACT EABORN TRUCKING