I certify that I personally completed this application and that all of the information is true and correct. I hereby request and authorize any company that receives this application to cause to be conducted, at any time, an investigation of my background for employment purposes, which may include, but is not limited to, any information relating to my character, general reputation, personal characteristics, mode of living, criminal history, past work experience, educational background, alcohol or drug test results, or failure to submit to an alcohol or drug test, or any other information about me which may reflect upon my potential for employment gathered from any individual, organization, entity, agency, or other source which may have knowledge concerning any such items of information. I have completed this application of my own free will and hold Delta Freight Systems. harmless of all liability for providing this application for my use.
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 (“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(“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.
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.
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 a prospective 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.