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Application for Employment - Synergistiks, Inc.

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Applicant Information

* First Name:  
       
* Last Name:  
       
Middle Name: 
       
Cell Number:   -  -

* Social Security Number:  -  -
  
* Phone Number:   -  -
       
* Date of Birth    /    / 

Email:             How did you find out about us? 

Address

* Street: 
       
* City: 
       
* State: 
   
* Zip: 
   
* Number of Years: 

Past 3 Year Residency
Street: 
       
City: 
       
State:   
  
Zip: 
   
Number of Years: 

Street: 
       
City: 
       
State:   
  
Zip: 
   
Number of Years: 

Employment History

All applicants wishing to drive in interstate commerce must provide the following information on all employers during the preceding three years. You must give the same information for all employers for whom you have driven a commercial vehicle seven years prior to the initial three years (total of ten year employment record).
You are required to list the complete mailing address: street number and name, city, state, and zip code
.

Current or Last Employer:
If this is your current job, check here:
Name:
       
Phone:  -  -
       
Address:
           
City: 
       
State:
   
Zip: 
       
Position Held: 
       
Salary/Wage: 
       
From:    /          To:    / 

Reasons for leaving: 

Were you subject to the FMCSRs while employed?
Was your job designated as a safety sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40?
Account for period between Jobs - Include dates (month/year) and reason: 


Second to Last Employer:
If this is also your current job, check here:
Name:        
Phone:  -  -        
Address:
           
City: 
       
State:
 
Zip:         
Position Held:         
Salary/Wage: 
       
From:    /          To:    / 

Reasons for leaving: 

Were you subject to the FMCSRs while employed?
Was your job designated as a safety sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40?
Account for period between Jobs - Include dates (month/year) and reason: 


Third Last Employer:
Name:        
Phone:  -  -        
Address:
           
City: 
        
State:
   
Zip: 
       
Position Held:         
Salary/Wage: 
       
From:    /          To:    / 

Reasons for leaving: 

Were you subject to the FMCSRs while employed?
Was your job designated as a safety sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40?
Account for period between Jobs - Include dates (month/year) and reason: 


Fourth Last Employer:
Name:        
Phone:  -  -
       
Address:
           
City: 
       
State:
  
Zip: 
       
Position Held: 
       
Salary/Wage: 
       
From:    /          To:    / 

Reasons for leaving: 

Were you subject to the FMCSRs while employed?
Was your job designated as a safety sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40?
Account for period between Jobs - Include dates (month/year) and reason: 


Fifth Last Employer:
Name:
       
Phone:  -  -
       
Address:
           
City: 
       
State:
    
Zip: 
       
Position Held: 
       
Salary/Wage: 
       
From:    /          To:    / 

Reasons for leaving: 

Were you subject to the FMCSRs while employed?
Was your job designated as a safety sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40?
Account for period between Jobs - Include dates (month/year) and reason: 

Sixth Last Employer:
Name:
       
Phone:  -  -
       
Address:
           
City: 
       
State:
    
Zip: 
       
Position Held: 
       
Salary/Wage: 
       
From:    /          To:    / 

Reasons for leaving: 

Were you subject to the FMCSRs while employed?
Was your job designated as a safety sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40?
Account for period between Jobs - Include dates (month/year) and reason: 

Seventh Last Employer:
Name:
       
Phone:  -  -
       
Address:
           
City: 
       
State:
    
Zip: 
       
Position Held: 
       
Salary/Wage: 
       
From:    /          To:    / 

Reasons for leaving: 

Were you subject to the FMCSRs while employed?
Was your job designated as a safety sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40?
Account for period between Jobs - Include dates (month/year) and reason: 

Eighth Last Employer:
Name:
       
Phone:  -  -
       
Address:
           
City: 
       
State:
    
Zip: 
       
Position Held: 
       
Salary/Wage: 
       
From:    /          To:    / 

Reasons for leaving: 

Were you subject to the FMCSRs while employed?
Was your job designated as a safety sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40?
Account for period between Jobs - Include dates (month/year) and reason: 

Ninth Last Employer:
Name:
       
Phone:  -  -
       
Address:
           
City: 
       
State:
    
Zip: 
       
Position Held: 
       
Salary/Wage: 
       
From:    /          To:    / 

Reasons for leaving: 

Were you subject to the FMCSRs while employed?
Was your job designated as a safety sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40?
Account for period between Jobs - Include dates (month/year) and reason: 

Experience and Qualification

If no driving experience in the last 3 years, check here:

Class of Equipment                        Type of Equipment                                                          Dates                                                                   Approximate Miles
                                                      (Mark all that apply)                                From                                To

Straight Truck      
Tractor & Semi-Trailer      
Tractor-Two Trailers      
Tractor-Three Trailers      OR
Motor Coach-School Bus  More than 8 Passengers      
Motor Coach-School Bus  More than 15 Passengers      

License Information

Section 383.21 FMCSR 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.

* State: 
        
* License Number: 
       
* Expiration Date:     /     / 

* Have you ever been denied a license, permit, or privilege to operate a motor vehicle?
    If Yes, give details: 
* Has any license, permit, or privilege ever been suspended or revoked?
    If Yes, give details: 

Accident History (3 years)

If no accidents within the last 3 years, check here:

Accident 1
Date:   / 
  
Nature of Accident: 
    
Number of Fatalities: 
 
Number of Injuries: 

Hazardous materials spill?
Accident 2
Date:    / 
 
Nature of Accident: 
   
Number of Fatalities: 
   
Number of Injuries: 

Hazardous materials spill?
Accident 3
Date:     / 
 
Nature of Accident: 
   
Number of Fatalities: 
   
Number of Injuries: 

Hazardous materials spill?

Traffic Convictions and Forfeitures (3 Years)

If no traffic convictions and/or forfeitures in the last 3 years, check here:

Violation 1
Date convicted:     / 
      
Violation (other than violations involving parking only): 
       
State of Violation:  
    
Penalty (Forfeited bond, collateral, and/or points):

Violation 2
Date convicted:      / 
      
Violation (other than violations involving parking only): 
       
State of Violation:  
     
Penalty (Forfeited bond, collateral, and/or points):

Violation 3
Date convicted:      / 
      
Violation (other than violations involving parking only): 
       
State of Violation: 
       
Penalty (Forfeited bond, collateral, and/or points):

* Have you ever been convicted of a felony?
   If Yes, please explain:     Date:      

* Education-Mark highest grade completed
  
   
High School                                   College
Last school attended:
* Name: 
       
* City: 
       
* State: 

Applicant Certification


AGREEMENT AND RELEASE (PLEASE READ THE FOLLOWING STATEMENT CAREFULLY)
 
     This certifies that my qualification form was completed by me and all entries on it are true and complete to the best of my knowledge. I also agree that falsified information and significant omissions may result in my disqualification now or at any time. I understand that Synergistiks uses an electronic filing and signature system which includes the imaging and storing of forms and applications. Therefore, my original paper application will not be retained. I understand that an electronic signature will be binding upon me to the same extent as if handwritten. I understand that my qualification can be terminated, with or without cause, at any time at the discretion of either Synergistiks or myself. In accordance with Section(s) 382.405, 382.413, & 391.23 of the FMCSR, I authorize any and all persons and/or institutions to provide any relevant information, including but not limited to my accident history, that may be required to complete my qualification and I agree to release them from any and all liability for supplying said information.



Synergistiks, Inc.
 
Consumer Reports Disclosure and Release
 
      In connection with my application for employment or to provide contractual services with Synergistiks, Inc., I understand that Synergistiks may obtain one or more consumer/background reports which may contain public record information, driving history, employment history, criminal history, and/or safety history from consumer reporting agencies, including but not limited to DAC Services (also known as HireRight), e-Verifile, The Work Number, Ten Street, and/or the Federal Motor Carrier Safety Administrations (FMCSA) via Pre-Employment Screening Program (PSP). These reports may include, but not be limited to the following types of information from federal, state, and other agencies which maintain such records:
 
  • 1. Names and dates of previous employment/contract services
  • 2. Reasons for termination of employment or termination of contract services
  • 3. Work Experience
  • 4. Accident history/Driving Record
  • 5. Previous records requests from other companies; and
  • 6. Criminal reports
 
Synergistiks cannot obtain consumer/background reports unless you consent in writing.
 
If you agree that Synergistiks may obtain such consumer/background reports, please read the following and sign below:

 
 
      I authorize Synergistiks to access the FMCSA PSP system and various consumer reports to seek information regarding my commercial driving safety record, safety inspection history, employment history and criminal records. I understand that my consent includes consent 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. Other reports may provide information from the previous seven (7) years. I understand and acknowledge that this release of information may assist Synergistiks to make a determination regarding my suitablity as a driver.
 
      If you desire to receive a copy of your investigative consumer/background reports that were provided to Synergistiks, you may do so by making such a request to Synergistiks and providing proper identification.
 
      I understand that neither Synergistiks 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 that 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 agency, FMCSA cannot change or correct this data. I understand my request will be forwarded by the DataQs system to the appropriate State agency for adjudication.
 
      If you desire to receive a copy of your investigative consumer/background reports that were provided to Synergistiks, if applicable, by PSP, HireRight/DAC Services, e-Verifile, Ten Street, or The Work Number, you may obtain a free copy from the respective consumer reporting agency within 60 days of your request. You may also dispute the accuracy or completeness of any information in your consumer/background reports via the contract information listed below:
 
      - HireRight, Inc./DAC Services 5151 California Avenue, Irvine, CA 92617
           1-800-490-7983
 
      - e-Verifile.com, Inc. 900 Circle 75 Parkway, Suite 1550 Atlanta, GA 30339
           1-800-853-3228, Ext. 3
 
      - PSP/FMCSA 1200 New Jersey Avenue, SE Washington, DC 20590
           1-800-832-5660
 
      - The Work Number 11432 Lackland, St. Louis, MO 53146
           1-866-662-3343
 
      - Ten Street 1120 Ease 25th Street, Tulsa, OK 74114-2614
           (877) 219-9283
 
      I have read the above Consumer Reports Disclosure and Release provided to me by Synergistiks, I understand that if I sign this consent form, Synergistiks may obtain a report of my work history, criminal history, driving, crash and inspection history. I further understand that if I am hired by Synergistiks or if Synergistiks contracts with me, that DriverFacts and DAC Services may obtain my work history with Synergistiks and that such history will be supplied by DAC Services and DriverFacts to other companies that subscribe to DAC Services and to DriverFacts to companies requesting information related to my work history with Synergistiks.
 
      I hereby authorize Synergistiks to obtain the information disclosed above. The authorization shall remain on file and shall serve as ongoing authorization for Synergistiks to obtain comsumer/background reports at any time during my employment or while providing contractual services for Synergistiks.
                                                                   
     
I agree to the Terms stated above.