DISCLOSURE & AUTHORIZATION FOR RELEASE OF INFORMATION
As a part of our hiring, a background check and investigation will be conducted. We may ask FleetScreen, a consumer reporting agency, to prepare a consumer report and an investigative consumer report prior to your being qualified in the service of TOP LOGISTICS, LLC. The consumer investigative report may consist of contacting all listed prior employers to verify your employment history, job performance and drug/alcohol testing data. It may also include a consumer report to include a check of applicable criminal police or court records. Under the provisions of the Fair Credit Reporting Act (15 USC at 1681-1681u) as amended, before we can seek such a report from FleetScreen, we must have your written permission for FleetScreen to obtain the information and to provide the information to us as part of our analysis of your application for employment with our company.
Below you will find an authorization and release for FleetScreen to prepare a consumer report, and for our company to receive, a copy of that report. If you do not wish to execute this release, please return all of the application materials to the person from whom you obtained them.
AUTHORIZATION & RELEASE TO OBTAIN CONSUMER REPORT
Under the provision of the Fair Credit Reporting Act, 15 USC, Section 1681 et. Seq., the Americans with Disability Act and all applicable federal, state and local laws, I hereby authorize and permit TOP LOGISTICS, LLC. to obtain from FleetScreen, a consumer report and investigative consumer report which may include the following:
My employment records
Records concerning any driving, criminal history, credit history, and civil records
For Truck Drivers Only- In accordance with the Department of Transportation Motor Carrier Safety Regulations, Section 382,413, information concerning alcohol and controlled substances use for the past three (3) years.
Verification of my academic and/or professional credentials; and information and/or copies of documents from any military service.
I understand that the above items, which may constitute “investigative consumer reports”, may include information as to my character, general reputation, personal characteristics, and mode of living which may be obtained by interviews with individuals with whom I am acquainted or who may have knowledge concerning any such items of information.
I agree that a copy of the authorization has the same effect as an original.
I hereby release and hold harmless any person, firm or entity that discloses matters in accordance with this authorization, as well as TOP LOGISTICS, LLC. and FleetScreen from liability that might otherwise result from the request for use of and/or disclosure of any or all of the foregoing information.
I understand and acknowledge that under provisions of the Fair Credit Reporting Act, I may request a copy of the consumer report or consumer investigative report from FleetScreen, the consumer reporting agency that compiled the report, after I have provided FleetScreen with proper identification. I also understand that before any adverse action is taken based, in whole or in part, on the information in the consumer report, I will be provided a copy of the report, the name, address and telephone number of Fleetscreen, and a summary of my rights under the Fair Credit Reporting Act.
I hereby authorize FleetScreen to obtain and prepare an investigative consumer report as set forth above and to provide that report to TOP LOGISTICS, LLC. as part of its investigation of my employment application.
REGARDING BACKGROUND REPORTS FROM THE PSP Online Service
In connection with your application for employment with TOP LOGISTICS, LLC. (“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. 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 . If you 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.
If you agree that the Prospective Employer may obtain such background reports, please read the following and sign below: I authorize TOP LOGISTICS, LLC. (“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 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 . 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.