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."
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Previous Addresses Last Three (3) Years
Please include Number, Street, City, State, and Zip Code.
Motor Vehicle Record
Accident Record for the Past Three (3) Years
Traffic Convictions and Forfeitures for Past Three (3) Years
Other Than Parking Violations
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.
List States Operated In for the Last Three (3) Years
Special Courses of Training
- 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.
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