Driver Application | US Cryo Carriers

Step 1 of 3

To Be Read & Signed By Apllicant
I authorize 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, 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, 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.
"I understand that information I provide regarding current and/or 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 (e).
I understand that I have the right to:
- Review information provided by current/previous employers;
- Have errors in the information corrected by previous employers and for those previous employers to re-send the corrected information to the prospective employer; 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."
Signature*
Date*
MM slash DD slash YYYY
Personal Information
First Name*
Last Name*
Address Line 1*
Address Line 2
City*
State / Province*
Postal Code*
Country
DOB
Previous Addresses Last Three (3) Years
Please include Number, Street, City, State, and Zip Code.
Address 1
Address 2
Address 3
Motor Vehicle Record
Accident Record for the Past Three (3) Years
Date
Nature of Accident
Fatalities
Injuries
Property Damage
Date
Nature of Accident
Fatalities
Injuries
Property Damage
Date
Nature of Accident
Fatalities
Injuries
Property Damage
Traffic Convictions and Forfeitures for Past Three (3) Years
Other Than Parking Violations
Location
Date
Charge
Penalty
Location
Date
Charge
Penalty
Location
Date
Charge
Penalty
Have you ever been denied a license, permit, or privilege to operate a motor vehicle?
Have you ever had any license, permit, or privilege suspended or revoked?
Past and Present Motor Vehicle Licenses
Section 383.21 FMC S R states "No person who operates a commercial motor vehicle shall at any time have more than one driver's license". I certify that I do not have more than one motor vehicle license, the information for which is listed below.
Current State*
License No.*
Type
Issue Date
Expiration Date*
Have you ever been denied a license, permit, or privilege to operate a motor vehicle?*
If yes, give details*
Have you ever had any license, permit, or privilege suspended or revoked?*
If yes, give details*
Past State
License No.
Type
Issue Date
Expiration Date
Have you ever been denied a license, permit, or privilege to operate a motor vehicle?*
If yes, give details*
Have you ever had any license, permit, or privilege suspended or revoked?*
If yes, give details*
Past State
License No.
Type
Issue Date
Expiration Date
Have you ever been denied a license, permit, or privilege to operate a motor vehicle?*
If yes, give details*
Have you ever had any license, permit, or privilege suspended or revoked?*
If yes, give details*
Experience
List States Operated In for the Last Three (3) Years
Class of Equipment
Type
Date From:
Date To:
Approx. No. of Miles
Class of Equipment
Type
Date From:
Date To:
Approx. No. of Miles
Class of Equipment
Type
Date From:
Date To:
Approx. No. of Miles
Class of Equipment
Type
Date From:
Date To:
Approx. No. of Miles
Class of Equipment
Type
Date From:
Date To:
Approx. No. of Miles
Special Courses of Training
Show special courses or training and/or safe driving awards you hold relative to your experience:
Certification
I CERTIFY THAT THIS APPLICATION WAS COMPLETED BY ME, THAT THE INFORMATION CONTAINED IN THIS APPLICATION IS CORRECT TO THE BEST OF MY KNOWLEDGE, AND I UNDERSTAND THAT FALSIFICATION OF THIS APPLICATION IN ANY DETAIL IS GROUNDS FOR DISQUALIFICATION FROM FURTHER CONSIDERATION OR FOR REMOVAL AS AN INDEPENDENT CONTRACTOR IN ACCORDANCE WITH THE INDEPENDENT CONTRACTOR AGREEMENT AND COMPANY POLICY. I AGREE TO ALLOW U.S. CRYO CARRIERS TO INVESTIGATE THE TRUTHFULNESS OF ALL STATEMENTS MADE ON THIS APPLICATION TO VERIFY PRIOR EMPLOYMENT AND TO CONTACT REFERENCES. IN ADDITION, I CONSENT FOR ALL CONTACTED PERSONS, INCLUDING FORMER EMPLOYERS, TO PROVIDE INFORMATION AND I RELEASE SUCH PERSON FROM LIABILITY FOR PROVIDING INFORMATION.
Signature*
Date
MM slash DD slash YYYY

Applicant Notification and Release Form
US Cryo Carriers
Applicant Notification
(FAIR CREDIT REPORTING ACT DISCLOSURE STATEMENT) In accordance with the provisions of Section 604 (b)(2)(A) of the Fair Credit Reporting Act, Public Law 91-508, as amended by the Consumer Credit Reporting Act of 1996 (Title II, Subtitle D, Chapter I, of Public Law 104-208), you are being informed that reports verifying your previous employment, previous drug and alcohol test results, and your driving record may be obtained on you for the purpose of a background investigation to see if you qualify for our program. These reports are required by Sections 382.413, 391.23 and 391.25 of the Federal Motor Carrier Safety Regulations.

Authorization and General Release
I hereby authorize US Cryo Carriers, and all of their agents, including Hire Right, Inc. of Irvine, CA, to request and receive any information and records concerning me, including but not limited to consumer credit, criminal record history, worker’s compensation claims, driving record, past employment history, military service, bankruptcy proceedings, civil and educational data and reports, from any individuals, corporations, partnerships, associations, institutions, schools, governmental agencies and departments, courts, law enforcement and licensing agencies, consumer reporting agencies and other federal, state agencies and entities, which maintain such records, including my present and previous employers. Information from Hire Right concerning previous driving record requests made by others from such state agencies, and state provided driving records would also be requested.

I further release and discharge US Cryo Carriers, all of their agents, all of their subsidiaries and affiliates, and every employee and agent of any of them, and all individuals and personal, business, private or public entities of any kind, including Hire Right, Inc. of Irvine, CA, from any and all claims and liability arising out of any request(s) for, or receipt of information or records pursuant to this authorization, or arising out of any compliance, with such request(s). I authorize the procurement of an investigative consumer report and understand that it may contain information about my character, general reputation, personal characteristics, and mode of living, whichever are applicable. I understand that I have the right to make a written request within a reasonable period of time to Hire Right, Inc. of Irvine, CA, 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 Hire Right has previously furnished within the two year period preceding my request. I hereby consent to your obtaining the above information from Hire Right, and I agree that such information which Hire Right has or obtains, and my contract history with you if I am contracted for services, will be supplied by Hire Right to other companies which subscribe to Hire Right Services.

Applicant’s Statement of Release
I HEREBY AUTHORIZE, WITHOUT RESERVATION, US CRYO CARRIERS, OR ANY PARTY OR AGENCY CONTACTED BY US CRYO CARRIERS, OR ITS PARTICIPATING COMPANIES, INCLUDING HIRE RIGHT, INC. OF IRVINE, CA, TO DO A COMPLETE BACKGROUND INVESTIGATION IN ACCORDANCE WITH STATE AND FEDERAL LAWS. I AUTHORIZE THE RELEASE OF ANY INFORMATION REGARDING MY EMPLOYMENT, INCLUDING, BUT NOT LIMITED TO ALL INFORMATION RELATED TO MY ALCOHOL AND CONTROLLED SUBSTANCE TESTING AND TRAINING RECORDS BY ANY FORMER EMPLOYERS, AND HOLD THEM HARMLESS OF ANY AND ALL LIABILITY FROM RELEASE OF SAID INFORMATION. IF CONTRACTED, THIS AUTHORIZATION SHALL REMAIN ON FILE AND SHALL SERVE AS ONGOING AUTHORIZATION FOR YOU TO PROCURE CONSUMER REPORTS AT ANY TIME DURING MY CONTRACT PERIOD OR UNTIL WITHDRAWN BY ME IN WRITING.
Date
MM slash DD slash YYYY
Signature*
Comments
This field is for validation purposes and should be left unchanged.

Step 1 of 3

To Be Read & Signed By Apllicant

Personal Information

Previous Addresses Last Three (3) Years

Motor Vehicle Record

Traffic Convictions and Forfeitures for Past Three (3) Years

Past and Present Motor Vehicle Licenses

Experience

Special Courses of Training

Certification

Employment for at Least the Past Ten (10) Years

Applicant Notification and Release Form

Applicant Notification

Authorization and General Release

Applicant’s Statement of Release