Full Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Have you been at this address for 3 or more years? *

Yes

No

Date of Birth *

MM

DD

YYYY

Phone Number

(###)

###

####

Can you provide proof that you are eligible to work in the U.S. if hired? *

Yes

No

Are you at least 21 years of age? *

Yes

No

Have you held a valid U.S. license for the past 36 months? *

Yes

No

Do you have a Class-A license? *

Yes

No

Do you have any restrictions? *

Yes

No

Expiration Date of License *

MM

DD

YYYY

Expiration Date of Physical DOT Card *

MM

DD

YYYY

CDL Endorsements *

Tanker

Doubles/Triples

Hazmat

X Endorsement

TWIC

None

Hazmat Expiration Date (if applicable)

MM

DD

YYYY

TWIC Expiration Date (if applicable)

MM

DD

YYYY

Have you been to truck driving school? *

Yes

No

Have you worked for Traverse Solutions in the past? *

Yes

No

Start Date (if applicable)

MM

DD

YYYY

End Date (if applicable)

MM

DD

YYYY

Is this your current employer?

Yes

No

Start Date

MM

DD

YYYY

End Date (if applicable)

MM

DD

YYYY

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Employer Phone Number

(###)

###

####

May we contact this employer at this time?

Yes

No

Was this a driving position?

Yes

No

Is this your current employer?

Yes

No

Start Date

MM

DD

YYYY

End Date (if applicable)

MM

DD

YYYY

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Employer Phone Number

(###)

###

####

May we contact this employer at this time?

Yes

No

Was this a driving position?

Yes

No

Is this your current employer?

Yes

No

Start Date

MM

DD

YYYY

End Date (if applicable)

MM

DD

YYYY

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Employer Phone Number

(###)

###

####

May we contact this employer at this time?

Yes

No

Was this a driving position?

Yes

No

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Did you graduate/equivalent? *

Yes

No

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Did you graduate/equivalent? *

Yes

No

Have you had any moving violations in the last 5 years? *

Yes

No

Has your license suspended ever been suspended? *

Yes

No

Have you had any accidents in the last 5 years? *

Yes

No

Have you ever had a DUI, DWI, or OVI? *

Yes

No

Have you ever been convicted of a felony? *

Yes

No

Have you ever been convicted of a misdemeanor? *

Yes

No

During the past two (2) years have you tested positive on a pre-employment alcohol or drug test administered by Employer to which you applied for but did not obtain a safety-sensitive transportation work covered by Department of Transportation (DOT) drug and alcohol testing rules? *

Yes

No

During the past two (2) years have you refused to test on a pre-employment alcohol or drug test administered by Employer to which you applied for but did not obtain a safety-sensitive transportation work covered by Department of Transportation (DOT) drug and alcohol testing rules? *

Yes

No

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, TRAVERSE SOLUTIONS (“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 (PMCSA). 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 base 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.fincsa.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 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 (PMCSR) violations that have been adjudicated by a court of!aw 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 TRAVERSE SOLUTIONS ("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 https://dataqs.fincsa.dot.gov. If I challenge a 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 al) 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.

I accept

I do not accept

By signing, I agree I have read the above statements

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