Enter the information below, then print the page or click Submit Online at the end of the form.

To Be Read And Signed By Applicant

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. I authorize you to make such investigations and inquires of my personal, employment, financial or medical history and other related matters as may be necessary. I hereby release employers, schools, health care providers and other personnel from all liability in responding to inquires and releasing information in connection with my application.

In the event I meet the required qualification, I understand that false or misleading information given in my application or interview(s) may result in termination of my employment. I understand also, that I am required to abide by all rules and regulations of the Company.

Date  

Signature (electronic signature)

Type your name in the box.

Driver Release

In connection with my application for qualification with you, I understand that an investigative consumer report is being requested from USIS/DAC Services, Tulsa Oklahoma and PEVS (Past Employment Verification), St. Joseph, Mo, which will include information as to my character, work habits, safety performance history (including accident history and drug & alcohol history in compliance with 40.25 and 391.23). Further, I understand that you will be requesting information concerning my driving record and/or information from various state agencies that maintain records concerning traffic offenses, USIS/DAC Services or PEVS concerning both previous driving record requests made by others from such state agencies and claims involving me in the files of insurance companies.

I understand I have the right to:

• Review information provided by previous employers
• Have errors in the information corrected by the previous employer, and for that previous employer to re-send the corrected information to the prospective employer
• 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

I hereby consent to your obtaining the above described information from USIS/DAC Services or PEVS, and agree that such information which USIS/DAC Services or PEVS has or obtains, and my qualifications and safety performance history with you if I am qualified, will be supplied by USIS/DAC Services or PEVS to other companies that subscribe to these services.

If qualified, I further consent to your furnishing to USIS/DAC Services information concerning my character, work habits, safety performance history (which includes accident and drug & alcohol history in compliance with 40.25 and 391.23) driving record and experience, as well as any reason for termination of my qualification. I further consent to USIS/DAC Services furnishing such information in the future to other companies which subscribe to USIS/DAC Services from which I may be seeking employment, and to insurance companies or their agents in connection with issuance or maintenance of insurance coverage. In addition, I understand that my MVR (Motor Vehicle Record) will be ordered through USIS/DAC Services, and reviewed at a minimum of once each year to determine my continued qualification to drive for Amstan Logistics, Inc.

Printed name   Social Security Number

Date  

Applicant's Electronic Signature