Please enable JavaScript in your browser to complete this form. - Step 1 of 3First name: *Middle name:Last name: *SSN / EIN: *Birth date: *MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Address *City: *State / Province: *ChooseAlabama (AL)Alaska (AK)Arizona (AZ)Arkansas (AR)California (CA)Colorado (CO)Connecticut (CT)Delaware (DE)District of Columbia (DC)Florida (FL)Georgia (GA)Hawaii (HI)Idaho (ID)Illinois (IL)Indiana (IN)Iowa (IA)Kansas (KS)Kentucky (KY)Luisiana (LA)Maine (ME)Mariland (MD)Massachusetts (MA)Michigan (MI)Minnesota (MN)Mississippi (MS)Missouri (MO)Montana (MT)Nebraska (NE)Nevada (NV)New Hampshire (NH)New Jersey (NJ)New Mexico (NM)New York (NY)North Carolina (NC)North Dakota (ND)Ohio (OH)Oklahoma (OK)Oregon (OR)Pennsylvania (PA)Rhode Island (RI)South Carolina (SC)South Dakota (SD)Tennessee (TN)Texas (TX)Utah (UT)Vermont (VT)Virginia (VA)Washington (WA)West Virginia (WV)Wisconsin (WI)Wyoming (WY)Zip / Postal: *Driver E-Mail: *Your phone number:Your cell number: *You are applying for: *Company driverTeam driverOwner operatorDriver for owner operatorYour experience:Less than 1 year1+2+3+4+5+Carriers you worked for in past 3y:012345+How many accidents have you been in during the last 36 months?012345+How many violations have you been cited for in the last 36 months?012345+Licence number: *Licence State / Province: *ChooseAlabama (AL)Alaska (AK)Arizona (AZ)Arkansas (AR)California (CA)Colorado (CO)Connecticut (CT)Delaware (DE)District of Columbia (DC)Florida (FL)Georgia (GA)Hawaii (HI)Idaho (ID)Illinoi (IL)Indiana (IN)Iowa (IA)Kansas (KS)Kentucky (KY)Luisiana (LA)Maine (ME)Mariland (MD)Massachusetts (MA)Michigan (MI)Minnesota (MN)Mississippi (MS)Missouri (MO)Montana (MT)Nebraska (NE)Nevada (NV)New Hampshire (NH)New Jersey (NJ)New Mexico (NM)New York (NY)North Carolina (NC)North Dakota (ND)Ohio (OH)Oklahoma (OK)Oregon (OR)Pennsylvania (PA)Rhode Island (RI)South Carolina (SC)South Dakota (SD)Tennessee (TN)Texas (TX)Utah (UT)Vermont (VT)Virginia (VA)Washington (WA)West Virginia (WV)Wisconsin (WI)Wyoming (WY)License expiration: *MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Type of driver's licence: *Non-CDLCDL Class AEndorsments: *NoneTankerX EndorsmentsDoubles / TriplesHazMatOtherNextPlease, read carefully listed documents and check all to proceedA Summary of Your Rights Under the Fair Credit Reporting Act *Check here if you accept these terms of FCRA.A Summary of Your Rights Under the Fair Credit Reporting ActPara information en espanol, visite www.consumerfinance.gov/learnmore o escribe a la Consumer Financial Protection Bureau, 1700 G Street N.W., Washington, DC 20552. A Summary of Your Rights Under the Fair Credit Reporting Act 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 www.consumerfinance.gov/learnmore or write to: Consumer Financial Protection Bureau, 1700 G Street, N.W., Washington, DC 20552. You must be told if information in your file has been used against you. Anyone who uses a credit report or another type of consumer report to deny your application for credit, insurance, or employment - or to take another adverse action against you - must tell you, and must give you the name, address, and phone number of the agency that provided the information. You have the right to know what is in your file. You may request and obtain all the information about you in the files of a consumer reporting agency (your "file disclosure"). You will be required to provide proper identification, which may include your Social Security number. In many cases, the disclosure will be free. You are entitled to a free file disclosure if: a person has taken adverse action against you because of information in your credit report; you are the victim of identify theft and place a fraud alert in your file; your file contains inaccurate information as a result of fraud; you are on public assistance; you are unemployed but expect to apply for employment within 60 days. In addition, all consumers are entitled to one free disclosure every 12 months upon request from each nationwide credit bureau and from nationwide specialty consumer reporting agencies. See www.consumerfinance.gov/learnmore for additional information. You have the right to ask for a credit score. 2/14 27-12-2019 5e0584be94069 December 26, 2019 10:14 pm 10:14 pmCredit scores are numerical summaries of your credit- worthiness based on information from credit bureaus. You may request a credit score from consumer reporting agencies that create scores or distribute scores used in residential real property loans, but you will have to pay for it. In some mortgage transactions, you will receive credit score information for free from the mortgage lender. You have the right to dispute incomplete or inaccurate information. If you identify information in your file that is incomplete or inaccurate, and report it to the consumer reporting agency, the agency must investigate unless your dispute is frivolous. See www.consumerfinance.gov/learnmore for an explanation of dispute procedures. Consumer reporting agencies must correct or delete inaccurate, incomplete, or unverifiable information. Inaccurate, incomplete or unverifiable information must be removed or corrected, usually within 30 days. However, a consumer reporting agency may continue to report information it has verified as accurate. Consumer reporting agencies may not report outdated negative information. In most cases, a consumer reporting agency may not report negative information that is more than seven years old, or bankruptcies that are more than 10 years old. Access to your file is limited. A consumer reporting agency may provide information about you only to people with a valid need -- usually to consider an application with a creditor, insurer, employer, landlord, or other business. The FCRA specifies those with a valid need for access. You must give your consent for reports to be provided to employers. A consumer reporting agency may not give out information about you to your employer, or a potential employer, without your written consent given to the employer. Written consent generally is not required in the trucking industry. For more information, go to www.consumerfinance.gov/learnmore. You may limit "prescreened" offers of credit and insurance you get based on information in your credit report. Unsolicited "prescreened" offers for credit and insurance must include a toll-free phone number you can call if you choose to remove your name and address from the lists these offers are based on. You may opt-out with the nationwide credit bureaus at 888-5-OPT-OUT (888-567-8688). You may seek damages from violators. If a consumer reporting agency, or, in some cases, a user of consumer 3/14 27-12-2019 5e0584be94069 December 26, 2019 10:14 pm 10:14 pmreports or a furnisher of information to a consumer reporting agency violates the FCRA, you may be able to sue in state or federal court. Identity theft victims and active duty military personnel have additional rights. For more information, visit www.consumerfinance.gov/learnmore. 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: TYPE OF BUSINESS: CONTACT: 1.a. Banks, savings associations, and credit unions with a. Consumer Financial Protection Bureau 1700 G total assets of over $10 billion and their affiliates. Street NW b. Washington, DC 20552 b. Federal Trade Such affiliates that are not banks, savings Commission: Consumer associations, Response Center - FCRA Washington, DC 20580 or credit unions also should list, in addition to (877) 382-4357 the CFPB: 2. To the extent not included in item 1 above: a. National banks, federal savings associations, and federal a. Office of the Comptroller of the Currency branches Customer and federal agencies of foreign banks b. State Assistance Group 1301 McKinney Street, Suite member 3450 Houston, banks, branches and agencies of foreign banks TX 77010-9050 b. Federal Reserve Consumer (other than Help Center PO federal branches, federal agencies, and insured Box 1200 Minneapolis, MN 55480 c. FDIC state Consumer Response branches of foreign banks), commercial lending Center 1100 Walnut Street, Box #11 Kansas companies City, MO 64106 d. owned or controlled by foreign banks, and National Credit Union Administration Office of organizations Consumer operating under section 25 or 25A of the Federal Protection (OCP) Division of Consumer Reserve Compliance and Act c. Nonmember Insured Banks, Insured State Outreach (DCCO) 1775 Duke Street Alexandria, Branches of VA 22314 Foreign Banks, and insured state savings associations d. Federal Credit Unions Asst. General Counsel for Aviation Enforcement & Proceedings Aviation Consumer Protection 3. Air carriers Division Department of Transportation 1200 New Jersey Avenue, S.E. Washington, DC 20590 Creditors Subject to Surface Transportation Board 5. Creditors Subject to Packers and Stockyards Act, 1921 6. Small Business Investment Companies 7. Brokers and Dealers Office of Proceedings, Surface Transportation Board Department of Transportation 395 E Street, S.W. Washington, DC 20423 Nearest Packers and Stockyards Administration area Supervisor Associate Deputy Administrator for Capital Access United States Small Business Administration 409 Third Street, SW, 8th Floor Washington, DC 20416 Securities and Exchange Commission 100 F Street NE Washington, DC 20549 8. Federal Land Banks, Federal Land Bank Associations, Federal Intermediate Credit Banks, and Production Credit Associations. Farm Credit Administration 1501 Farm Credit Drive McLean, VA 22102-5090 9. Retailers, Finance Companies, and All Other Creditors Not Listed Above FTC Regional Office for region in which the creditor operates or Federal Trade Commission: Consumer Response Center - FCRA Washington, DC 20580 (877) 382-4357AUTHORIZATION *Check here if you accept above languageAUTHORIZATIONIMPORTANT DISCLOSURE REGARDING BACKGROUND REPORTS FROM THE PSP Online Service In connection with your application for employment with USA Freight, 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. AUTHORIZATION If you agree that the Prospective Employer may obtain such background reports, please read the following and sign below: I authorize USA Freight, 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 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.ADDITIONAL STATE LAW NOTICES *Check here if you accept these terms.ADDITIONAL STATE LAW NOTICESAdditional State Law Notices If you are a California, Maine, Massachusetts, New York or Washington State applicant, employee or contractor, please also note: CALIFORNIA: Pursuant to section 1786.22 of the California Civil Code, you may view the file maintained on you by SambaSafety and HireRight during normal business hours. You may also obtain a copy of this file, upon submitting proper identification and paying the actual copying costs, by appearing at SambaSafety or HireRight's offices in person, during normal business hours and on reasonable notice, or by certified mail. You may also receive a summary of the file by telephone, upon submitting proper identification and written request. SambaSafety and HireRight has trained personnel available to explain your file to you, including any coded information, and will provide a written explanation of any coded information contained in your file. 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, SambaSafety and HireRight may require additional information concerning your employment and personal or family history to verify your identity. MAINE: You have the right, upon request, to be informed of whether an investigative consumer report was requested, and if one was requested, the name and address of the consumer reporting agency furnishing the report. You may request and receive from the Company, within five business days of our receipt of your request, the name, address and telephone number of the nearest unit designated to handle inquiries for the consumer reporting agency issuing an investigative consumer report concerning you. You also have the right, under Maine law, to request and promptly receive from all such agencies copies of any such reports. MASSACHUSETTS: If we request an investigative consumer report, you have the right, upon written request, to a copy of the report. NEW YORK: You have the right, upon written request, to be informed of whether or not an investigative consumer report was requested. If an investigative consumer report is requested, you will be provided with the name and address of the consumer reporting agency furnishing the report. You may inspect and receive a copy of the report by contacting that agency. Please see https://www.HireRight.com/NY_Article_23_A.pdf?enable_url=true for additional information about New York law, as applicable. WASHINGTON STATE: If the Company requests an investigative consumer report, you have the right, upon written request made 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 also have the right to request from the consumer reporting agency a written summary of your rights and remedies under the Washington Fair Credit Reporting Act.CONSUMER DISCLOSURE AND AUTHORIZATION FORM *Check here if you accept these termsCONSUMER DISCLOSURE AND AUTHORIZATION FORMCONSUMER DISCLOSURE AND AUTHORIZATION FORM Disclosure Regarding Background Investigation USA Freight, Inc (the "Company") may request, for lawful employment purposes, background information about you from a consumer reporting agency in connection with your employment or application for employment (including independent contractor assignments, as applicable). This background information may be obtained in the form of consumer reports and/or investigative consumer reports (commonly known as "background reports"). These background reports may be obtained at any time after receipt of your authorization and, if you are hired or engaged by the Company, throughout your employment or your contract period. SambaSafety, HireRight, LLC, or another consumer reporting agency, will prepare or assemble the background reports for the Company. HireRight, LLC is located and can be contacted by mail at 3349 Michelson Dr. Suite 150, Irvine, CA 92612, and HireRight can be contacted by phone at (800) 400-2761. Information about HireRight's privacy practices is available at www.hireright.com/Privacy-Policy.aspx. The background report may contain information concerning your character, general reputation, personal characteristics, mode of living, and credit standing. The types of information that may be obtained include, but are not limited to: social security number verifications; address history; credit reports and history; criminal records and history; public court records; driving records; accident history; worker's compensation claims; bankruptcy filings; educational history verifications (e.g., dates of attendance, degrees obtained); employment history verifications (e.g., dates of employment, salary information, reasons for termination, etc.); personal and professional references checks; professional licensing and certification checks; drug/alcohol testing results, and drug/alcohol history in violation of law and/or company policy; and other information bearing on your character, general reputation, personal characteristics, mode of living and credit standing. This information may be obtained from private and public record sources, including, as appropriate: government agencies and courthouses; educational institutions; former employers; personal interviews with sources such as neighbors, friends and associates; and other information sources. If the Company should obtain information bearing on your credit worthiness, credit standing or credit capacity for reasons other than as required by law, then the Company will use such credit information to evaluate whether you would present an unacceptable risk of theft or other dishonest behavior in the job for which you are being evaluated. You may request more information about the nature and scope of any investigative consumer reports by contacting the Company.Authorization of Background Investigation *Check here if you accept these termsAuthorization of Background InvestigationAuthorization of Background Investigation I have carefully read and understand this Disclosure and Authorization form and the attached summary of rights under the Fair Credit Reporting Act. By my signature below, I consent to preparation of background reports by a consumer reporting agency such as SambaSafety, HireRight, LLC, and to the release of such background reports to the Company and its designated representatives and agents, for the purpose of assisting the Company in making a determination as to my eligibility for employment (including independent contractor assignments, as applicable), promotion, retention or for other lawful employment purposes. I understand that if the Company hires me or contracts for my services, my consent will apply, and the Company may obtain background reports, throughout my employment or contract period. I understand that information contained in my employment or contractor application, or otherwise disclosed by me before or during my employment or contract assignment, if any, may be used for the purpose of obtaining and evaluating background reports on me. I also understand that nothing herein shall be construed as an offer of employment or contract for services. I hereby authorize law enforcement agencies, learning institutions (including public and private schools and universities), information service bureaus, credit bureaus, record/data repositories, courts (federal, state and local) , motor vehicle records agencies, my past or present employers, the military, and other individuals and sources to furnish any and all information on me that is requested by the consumer reporting agency. By my signature below, I also certify the information I provided on and in connection with this form is true, accurate and complete. I agree that this form in original, faxed, photocopied or electronic (including electronically signed) form, will be valid for any background reports that may be requested by or on behalf of the Company.DISCLOSURE AND RELEASE *Check here if you accept these termsDISCLOSURE AND RELEASEDISCLOSURE AND RELEASE In accordance with DOT Regulation 49 CFR Part 391.23, I authorize the release of information from my DOT regulated drug and alcohol testing records by the carriers (company/school) listed above to USA Freight, Inc, or SambaSafety and HireRight for the sole purpose of transmitting such records to USA Freight, Inc. I authorize release of the following information concerning DOT drug and alcohol testing violations including pre-employment tests during the past three years: (i) alcohol tests with a result of 0.04 or higher; (ii) verified positive drug tests; (iii) refusals to be tested (including verified adulterated or substituted results); (iv) other violations of DOT drug and alcohol testing regulations; (v) information obtained from previous employers of a drug and alcohol rule violation(s); and (vi) documents, if any, of completion of a return-to-duty process following a rule violation. I also authorize the carriers (company/school) listed above to release information about names and dates of previous employers, reasons for termination of employment, work experience, accidents, academic history, professional credentials and other information. The information that I have authorized USA Freight, Inc, SambaSafety and HireRight to review involves tests required by DOT. If any carrier (company/school) listed above furnishes USA Freight, Inc, SambaSafety and HireRight with information concerning items (i) through (vi) above, I also authorize that carrier (company/school) to release and furnish the dates of my negative drug and/or alcohol tests and/or tests with results below 0.04 during the three-year period and the name and phone number of any substance abuse professional who evaluated me during the past three years.PreviousNextIf you agree with all please sign: * Clear Signature PreviousWebsiteSubmit