OTR Driver

- Step 1 of 11

In compliance with Federal and State equal opportunity laws, qualified applicants are considered for all poisitions without regard to race, color, religion, sex, national origin, age, marital status, veteran status, non-job related disability, or any other protected group status.

Name *

First

Middle

Last

Maiden Name

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Date of application *

Date of birth *

Who referred you?

Email *

Phone Number *

List your addresses of residency for the past 3 years. Starting with your current address first.

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Address *

State *

Year(s) *

City *

Zip Code *

Month(s) *

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Address

State

Year(s)

City

Zip Code

Month(s)

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Address

State

Year(s)

City

Zip Code

Month(s)

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Address

State

Year(s)

City

Zip Code

Month(s)

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Have you ever been previously employed by Carlyle Van Lines? *

Are you willing to submit to a controlled substance test? *

What type of driving position are you applying for? *

Are you a U.S. citizen? *

Can you perform, with or without reasonable accommodation, the essential functions of the job? *

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What is the highest level of education completed? *

Number of years/hours completed *

Type of degree or certification *

Do you have any safe driving awards? *

List awards and from whom *

Do you have experience moving military household goods? *

Years of experience *

Have you taken any special courses or training that help you as a driver? *

List courses or training that you have taken *

List accidents for the past 3 years. If none leave blank

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Date

Nature of accident

Fatalities or Injuries

Hazardous Material Spill

Explanation of all fatalities or injuries that occured

List traffic convictions and forfeitures for the past 3 years not including parking violations. If none leave blank.

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Location

Date

Charge

Penalty

Driver licenses or permits held in the past 3 years. Start with current/most recent first.

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State *

State

License Number *

License Number

Class and Endorsements

Expiration Date *

Expiration Date

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Have you ever been denied a license, permit, or privilege to operate a motor vehicle? *

Has any license, permit, or privilege ever been suspended or revoked? *

If you answered yes to either question give more details.

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Straight Truck *

Tractor and Semi-Trailer *

Tractor Two Trailers *

Tractor Three Trailers *

Other

Type of Equipment

Date From

Date To

List states you have operated in the last 5 years?

All driver applicants to drive in interstate commerce must provide the following information on all employers during the preceding 3 years.

Applicants to drive a commercial motor vehicle* in intrastate or interstate commerce shall also provide an additional 7 years' information on those employers for whom the applicant operated such vehicle.

(NOTE: List employers in reverse order starting with the most recent.)

Work History 1

Company Name

Zip Code

From Date

Reason for Leaving

Address

Contact Person

To Date

City

Phone Number

Position Held

State

Salary/Wage/Percent

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?

Work History 2

Company Name

Zip Code

From Date

Reason for Leaving

Address

Contact Person

To Date

City

Phone Number

Position Held

State

Salary/Wage/Percent

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?

Work History 3

Company Name

Zip Code

From Date

Reason for Leaving

Address

Contact Person

To Date

City

Phone Number

Position Held

State

Salary/Wage/Percent

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?

Work History 4

Company Name

Zip Code

From Date

Reason for Leaving

Address

Contact Person

To Date

City

Phone Number

Position Held

State

Salary/Wage/Percent

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?

Work History 5

Company Name

Zip Code

From Date

Reason for Leaving

Address

Contact Person

To Date

City

Phone Number

Position Held

State

Salary/Wage/Percent

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?

Work History 6

Company Name

Zip Code

From Date

Reason for Leaving

Address

Contact Person

To Date

City

Phone Number

Position Held

State

Salary/Wage/Percent

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?

Work History 7

Company Name

Zip Code

From Date

Reason for Leaving

Address

Contact Person

To Date

City

Phone Number

Position Held

State

Salary/Wage/Percent

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?

Work History 8

Company Name

Zip Code

From Date

Reason for Leaving

Address

Contact Person

To Date

City

Phone Number

Position Held

State

Salary/Wage/Percent

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?

Work History 9

Company Name

Zip Code

From Date

Reason for Leaving

Address

Contact Person

To Date

City

Phone Number

Position Held

State

Salary/Wage/Percent

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?

Work History 10

Company Name

Zip Code

From Date

Reason for Leaving

Address

Contact Person

To Date

City

Phone Number

Position Held

State

Salary/Wage/Percent

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?

Work History 11

Company Name

Zip Code

From Date

Reason for Leaving

Address

Contact Person

To Date

City

Phone Number

Position Held

State

Salary/Wage/Percent

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?

Work History 12

Company Name

Zip Code

From Date

Reason for Leaving

Address

Contact Person

To Date

City

Phone Number

Position Held

State

Salary/Wage/Percent

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?

*Includes vehicles having a GVWR of 26,001 lbs. or more, vehicles designed to transport 16 or more passengers (including the driver), or any size vehicle used to transport hazardous materials in a quantity requiring placarding.

**The Federal Motor Carrier Safety Regulations (FMCSRs) apply to anyone operating a motor vehicle on a highway in interstate commerce to transport passengers or property when the vehicle: (1) weighs or has a GVWR of 10,001 pounds or more, (2) is designed or used to transport more than 8 passengers (including the driver), or (3) is of any size and is used to transport hazardous materials in a quantity requiring placarding.

CARLYLE VAN LINES AUTHORIZATION TO RELEASE INFORMATION

(Please read the following information before signing and submitting this authorization.)

In consideration of Carlyle Van Lines' acceptance and review of my employment application (including contract for services), I agree to the following:

I authorize Carlyle Van Lines to investigate my background and gather all information that it finds relevant in considering my application for employment. I authorize investigative background inquiries, including, but not limited to, criminal convictions, motor vehicle reports, employment history reports, credit reports, and other reports. I understand that these reports will include information about my character, work habits, performance, experiences, education, and reasons for termination from past employment. I understand and authorize that Carlyle Van Lines may request this information from various federal, state, county, or other public or private sources that maintain records concerning my past activities related to my driving, criminal, credit, civil, or other experiences.

I also authorize Carlyle Van Lines to request information from any public agency, employer, or insurance company that maintains records concerning my past workers' compensation experience or claims. I understand that such workers' compensation information will only be obtained after an offer of employment has been extended to me.

I authorize Carlyle Van Lines to contract with any party or agency to furnish/collect the information set forth above.

I consent to Carlyle Van Lines or its agent obtaining the above information, and I release and forever discharge Carlyle Van Lines, its agents, and any other party, person, or corporation supplying the foregoing information from all liability or responsibility in connection with supplying and/or gathering the foregoing information. I further release Carlyle Van Lines and all other parties from any claims, damages, losses, liabilities, costs and expenses, or any other charge or complaint filed with any agency, court, or administrative body arising from the retrieving, reporting, and use of this information.

Agreement *

I have read the above and understand the same.

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Signature *

Date *

ACKNOWLEDGMENTS & AUTHORIZATIONS REGARDING BACKGROUND INVESTIGATION FOR EMPLOYMENT PURPOSES

Disclosures:

Investigative Consumer Report:

Carlyle Van Lines Inc. (the "Company") may request an investigative consumer report about you from HireRight, LLC ("HireRight"), a consumer reporting agency, in connection with your employment, application for employment, or engagement for services (including independent contractor or volunteer assignments, as applicable). An "investigative consumer report" is a background report that includes information from personal interviews (except in California, where that term includes background reports with or without information obtained from personal interviews), the most common form of which is checking personal or professional references through interviews with sources such as your former employers and associates, and other information sources. The investigative consumer report may contain information concerning your character, general reputation, personal characteristics, mode of living, or credit standing. The types of background information that may be obtained include, but are not limited to criminal history, litigation history, motor vehicle record and accident history, social security number verification, address and alias history, credit history, verification of your education, employment and earnings history, professional licensing, credential and certification checks, drug/alcohol testing results and history, military service, and other information.

You may request more information about the nature and scope of an investigative consumer report, if any, by contacting the Company.

Ongoing Authorization:

If the Company hires you or contracts for your services, the Company may obtain additional consumer reports and investigative consumer reports about you without asking for your authorization again, throughout your employment or your contract period, as allowed by law.

Additional State Law Notices:

Please see the "Additional State Law Notices" for California, Massachusetts, Minnesota, New Jersey, New York, and Washington that are provided below, as applicable. A California disclosure and summary of your rights under California Civil Code Section 1786.22, and a copy of New York Article 23-A, are being provided to you separately.

Summary of Rights under the Fair Credit Reporting Act:

A summary of your rights under the Fair Credit Reporting Act is being provided to you separately.

San Francisco Fair Chance Ordinance Official Notice: A copy of the San Francisco Fair Chance Ordinance Official Notice is being provided to you separately.

HireRight Privacy Policy:

Information about HireRight's privacy practices is available at www.hireright.com/Privacy-Policy.aspx.

Acknowledgments & Authorization:

I acknowledge that I have received and carefully read and understand the separate "Disclosure and Authorization Regarding Background Investigation for Employment Purposes" and the separate "Summary of Rights under the Fair Credit Reporting Act" that have been provided to me by the Company. I also acknowledge receipt of and that I have carefully read and understand (as applicable), the separate California Disclosure and Summary of Rights under California Civil Code Section 1786.22; the separate New York Article 23-A; and the separate San Francisco Fair Chance Ordinance Official Notice that have been provided to me. By my signature below, I authorize the preparation of background reports about me, including "investigative consumer reports" by HireRight. I understand that these reports will be furnished to the Company and its designated representatives and agents for the purpose of evaluating my eligibility for employment, engagement for services, promotion, retention, or other lawful employment purposes. I acknowledge that if I am hired or contracted by the Company, this consent will apply, and the Company may obtain additional background reports from HireRight or other consumer reporting agencies as allowed by law, without requiring my authorization again during my employment or contract period.

I am aware that if the Company obtains a credit report about me, it will only do so when the information is substantially relevant to the duties and responsibilities of the position for which I am being considered.

I understand that the information provided in my employment, contractor, or volunteer application, as well as any information disclosed by me during my employment or assignment, may be used to obtain and evaluate background reports. I acknowledge that nothing in this authorization should be construed as an offer of employment or contract for services.

I acknowledge that the background reports may include information obtained from various sources, including but not limited to government agencies, educational institutions, employers, law enforcement, courts, testing agencies, credit bureaus, motor vehicle records agencies, and other public and private record/data repositories. I hereby authorize these entities to disclose information about me to the consumer reporting agency and its agents. The disclosed information may cover various aspects, such as employment and earnings history, education, credit, motor vehicle and accident history, drug/alcohol testing results, criminal history, litigation history, military service, professional licenses, credentials and certifications, social security number verification, address and alias history, and other relevant information.

By signing below, I also confirm that all personal information provided with this form or during the background investigation process is true, accurate, and complete. I understand that any dishonesty or material omission may disqualify me from consideration for employment.

I agree that copies of this document in faxed, photocopied, or electronic form, including electronically signed copies, shall be considered as valid as the original signed document. Furthermore, I acknowledge that I have received additional state law notices, which I have reviewed and read.

Additional State Law Notices:

Please be advised that additional state-specific notices apply.

CALIFORNIA: Pursuant to section 1786.22 of the California Civil Code, you have the right to access and review the file maintained on you by the consumer reporting agency during normal business hours. If you wish to obtain a copy of this file, you can do so by visiting the consumer reporting agency's offices in person, during normal business hours and upon providing proper identification. Please note that you may be required to pay the actual copying costs for the requested documents. Alternatively, you can request a copy of the file by certified mail.

Furthermore, you have the option to receive a summary of your file by telephone. To request a telephone summary, you need to submit a written request along with proper identification. The consumer reporting agency has staff members who are trained to assist you and explain the contents of your file, including any coded information. Additionally, if there is any coded information in your file, the consumer reporting agency will provide a written explanation of its meaning.

Please be aware that these rights are provided to you under the California Civil Code, and the consumer reporting agency is obligated to comply with these requirements.

If you appear in person, you may be accompanied by one other person, provided that person furnishes proper identification. "Proper identification" includes documents such as a valid driver's license, social security account number, military identification card, and credit cards. If you cannot identify yourself with such information, the consumer reporting agency may require additional information concerning your employment and personal or family history to verify your identity.

HireRight, LLC ("HireRight") will prepare the background report for the Company. HireRight is located and can be contacted at 3349 Michelson Drive, Suite 150, Irvine, CA 92612, (800) 400-2761. Information about HireRight's privacy practices is available at www.hireright.com/Privacy-Policy.aspx.

MASSACHUSETTS: Upon request to the Company, you have the right to know whether the Company requested an investigative consumer report about you and, upon written request to the Company, you have the right to receive a copy of any such report. You also have the right to ask the consumer reporting agency (e.g., HireRight) for a copy of any such report.

MINNESOTA: You have the right in most circumstances to submit a written request to the consumer reporting agency (e.g., HireRight) for a complete and accurate disclosure of the nature and scope of any consumer report the Company ordered about you. The consumer reporting agency must provide you with this disclosure within 5 days after (i) its receipt of your request or (ii) the date the report was requested by the Company, whichever date is later.

NEW JERSEY: You have the right to submit a request to the consumer reporting agency (e.g., HireRight) for a copy of any investigative consumer report the Company requested about you.

NEW YORK: You have the right, upon written request to the Company, to be informed of whether the Company requested a consumer report or an investigative consumer report about you. Shown above is the address and telephone number for HireRight, the consumer reporting agency used by the Company. You may inspect and receive a copy of any such report by contacting that consumer reporting agency. A copy of Article 23-A of the New York Correction Law is also provided below.

WASHINGTON STATE: If the Company requests an investigative consumer report, you have the right, upon written request made to the Company within a reasonable period of time after your receipt of this disclosure, to receive from the Company a complete and accurate disclosure of the nature and scope of the investigation requested by the Company. You are entitled to this disclosure within 5 days after the date your request is received or the Company ordered the report, whichever is later. You also have the right to request a written summary of your rights and remedies under the Washington Fair Credit Reporting Act.

Agreement *

I have read the above and understand the same.

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Signature *

Date *

THE BELOW DISCLOSURE AND AUTHORIZATION LANGUAGE IS FOR MANDATORY USE BY ALL ACCOUNT HOLDERS

IMPORTANT DISCLOSURE REGARDING BACKGROUND REPORTS FROM THE PSP Online Service

In connection with your application for employment with Carlyle Van Lines ("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 not to 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 on 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 not to 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 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 https://dataqs.fmcsa.dot.gov. 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 be displayed on your PSP report. Since the PSP report does not report, 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.

AUTHORIZATION

If you agree that the Prospective Employer may obtain such background reports, please read the following and sign below:

I authorize Carlyle Van Lines ("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 in making 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 https://dataqs.fmcsa.dot.gov. 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 be displayed on my PSP report. Since the PSP report does not report, 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 a 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.

Agreement *

I have read the above and understand the same.

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Signature *

Date *

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 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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Signature *

Date *

The following information is needed solely for a criminal and/ or driving record check:

To Applicant: Federal and state Law protect you from discrimination in employment on the basis of age, sex and minority status. This employer is an Equal Opportunity Employer and intends to comply fully with those laws. This information is being requested solely for the purposes of a criminal and / or driving record check. This information is not part of your employment application, nor will it be used in considering your employment application.

This information will not be kept in your personnel file.

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Race *

Gender *

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