In accordance with DOT Regulation 49 CFR Part 391.23, I hereby authorize release of my DOT - regulated drug and alcohol testing records by the DOT - regulated employer (s) listed below to HireRight for the purpose of HireRight transmitting such records to the HireRight customer listed above . I understand that information / documents released pursuant to this Part I is limited to the following DOT - regulated testing items , including pre - employment testing results , occurring during the previous three (3) years : (i) alcohol tests with a result of 0.04 or higher; (ii) verified positive drug tests; (iii) refusals to be tested (including adulterated and/ or substituted tests) ; (iv) other violations of DOT drug and alcohol testing regulations (i.e., violations of 49 CFR 382 Subpart B); (v) information obtained from previous employers of a drug and alcohol rule violation; and (vi) any documentation of completion of the return - to - duty process following a rule violation.
If any company listed below furnishes HireRight with information concerning items (i) through (vi) above, I also authorize such company to furnish the following information to HireRight , if applicable: (i) dates of my negative drug and/or alcohol tests and/or tests with results below 0.04 during the previous three (3) years ; and (ii) the name and phone number of any substance abuse professional who evaluated me during the previous three (3) years
By signing below, I certify that: (i) all information provided herein is complete and accurate; (ii) I have read and fully understand this Part I disclosure and authorization for release as well as the attached FMCSA Notification of Driver Rights and any applicable state law notices; (i ii) prior to signing I was given an opportunity to ask questions and to have those questions answered to my satisfaction; (iv) I execute this authorization voluntarily and with the knowledge that the information obtained pursuant to this authorization could affect my eligibility for employment, promotion, retention or other lawful purpose; (v) I understand I may review this document with legal counsel prior to signing; and (vi) facsimile or photographic copies of this authorization are as valid as an original.
In compliance with 49 CFR Part 40 §391.23 you have certain rights regarding the safety performance history information that will be provided to prospective employers. I) You have the right to review information provided by previous employers. II) You have the right to have errors in the information corrected by the previous employer and for that previous employer to re-send the corrected information to prospective employers. III) You have the right to have a rebuttal statement attached to the alleged erroneous information, if the previous employer and the driver cannot agree on the accuracy of the information. (2) Drivers who have previous DOT regulated employment history in the preceding three years and wish to review previous employer-provided investigative information must submit a written request to prospective employers. This may be done at any time, including when applying, or as late as 30 days after being employed or being notified of denial of employment. Prospective employers must provide this information within five business days of receiving the written request. If prospective employers have not yet received the requested information from the previous employer, then the five day deadline will begin when the requested safety performance history information is received. If you have not arranged to pick up or receive the requested records within 30 days of prospective employers making them available, the prospective employers may consider you to have waived your request to review the record.
In connection with your application for employment with Naegeli Transportation Inc. (“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
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 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 Naegeli Transportation Inc. (“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.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
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.
NOTICE: This form is made available to monthly account holders by NIC 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 contained in this Disclosure and Authorization form to obtain an Applicant’s consent. The
language must be used in whole, exactly as provided. Further, the language on this form must exist as one stand-alone document. The language may NOT be included
with other consent forms or any other language.
Naegeli Transportation Inc. (the “Company”) may request from a consumer reporting agency and for
employment-related purposes, a
(commonly known as “background reports”)
containing background information about you in connection with your employment, or application for
employment, or engagement for services (including independent contractor or volunteer assignments, as
HireRight, LLC (“HireRight”) will prepare or assemble the background reports for the Company.
HireRight is located and can be contacted at 3349 Michelson Drive, Suite 150, Irvine, CA 92612, (800)
The background report(s) 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.
I hereby authorize Company to obtain the consumer reports described above about me.
HireRight, Inc. will be verifying the information
you provided to Naegeli Transportation Inc.
during the pre-employment process and
researching background information at our
request. Our objective is to complete this
process quickly. Please make every effort to
accurately provide all of the information
requested on the application. A HireRight
associate may contact you for additional
information during the verification process.
Please return the associate’s call or e-mail
promptly to help ensure that your application is
processed as quickly as possible.
The Naegeli Transportation Inc. Recruiting Team
In compliance with Federal and State equal employment opportunity laws, qualified applicants are considered for all
positions without regard to race, color, religion, sex, national origin, age, marital status, veteran status, non-job related
disability, or any other protected group status.
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 I have the right to:
List your addresses of residency for the past 3 years.
All driver applicants to drive in interstate commerce must provide the
following information on all employers during the preceding 3 years.
List complete mailing address, street number, city, state, and zip code.
Applicants to drive a commercial motor vehicle* in intrastate or
interstate commerce shall also provide an additional 7years' information
on those employers for whom the applicant operated such vehicle.(NOTE:
List employers in reverse order starting with the most recent. Add
another sheet as necessary.)
* 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
� 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 8 or
more passengers (including the driver), OR (3) is of any size and is
used to transport hazardous materials in a quantity requiring
ACCIDENT RECORD FOR PAST 3 YEARS OR MORE (ATTACH SHEET IF MORE SPACE IS NEEDED) IF NONE, WRITE NONE
TRAFFIC CONVICTIONS AND FORFEITURES FOR THE PAST 3 YEARS (OTHER THAN PARKING VIOLATIONS) IF NONE, WRITE NONE
This certifies that this application was completed by me, and that all entries on it and information in it are true and complete to the best of my knowledge.
RECIPIENT EMPLOYER: The individual identified in SECTION 1
below has indicated that you employ(ed) or used him/her within the last
3 years in a position that involved the operation of a commercial motor
vehicle and/or that was subject to U.S. Department of Transportation
(DOT)-regulated drug and alcohol testing.
In accordance with 49 CFR §§40.25 and 391.23, we are hereby
requesting that you supply us with the Safety Performance History of
this individual. Under DOT rule §391.23(g), you must respond to
this inquiry within 30 days of receipt.
Please complete SECTION 2 below, complete SECTIONS 3 and 4 (if
PROSPECTIVE EMPLOYEE: Complete SECTION 1 and submit to
PROSPECTIVE EMPLOYER: Complete SECTION 5a and send to current
/ previous employer. Upon receipt of completed form, complete SECTION 5b
Complete the following for any accidents
included on your accident register (§390.15(b))
that involved the applicant in the 3 years prior to the
application date shown on SIDE 1, or check here
if there is no accident register data for this driver.
The federal Fair Credit Reporting Act (FCRA) promotes the accuracy, fairness, and privacy of
information in the files of consumer reporting agencies. There are many types of consumer
reporting agencies, including credit bureaus and specialty agencies (such
as agencies that sell
information about check writing histories, medical records, and rental history records). Here is a
summary of your major rights under the FCRA.
For more information, including information
about additional rights, go to
or write to: Consumer
Financial Protection Bureau, 1700 G Street N.W., Washington, DC 20552.
States may enforce the FCRA, and many states have their own consumer reporting laws. In some cases, you may have more rights under state law. For more information, contact your state or local consumer protection agency or your state Attorney General. For Information about your Federal rights contact: