Personal Information

* All required fields must be completed


License Information

Endorsements


Background Information

If "Yes" please explain in the additonal comments section.

Preferences

Experience

Location


Employment History

(10 years history required)

Last or Current Employer


Prior Employer


Prior Employer

DOT Employee Drug and Alcohol Statement

The employee is required by 49 CFR Part 40.25 to answer the following question:

Have you tested positive, or refused to test, on any pre-employment drug or alcohol test administered by an employer to which you applied for, but did not obtain, safety-sensitive transportation work covered by DOT agency drug and alcohol testing rules during the past two years (or three years if a CDL Driver)?


MANDATORY USE FOR ALL ACCOUNT HOLDERS

IMPORTANT DISCLOSURE
REGARDING BACKGROUND REPORTS FROM THE PSP Online Service

In connection with your application for employment with FIRST RIVER Energy (“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 FIRST RIVER Energy (“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.


DISCLOSURE TO CONSUMER

FIRST RIVER ENERGY

As part of our employment process, we may obtain where permitted, one or more consumer reports or investigative consumer reports about you that we obtain from a consumer reporting agency, such as:

iiX, a Verisk Analytics Business
1716 Briarcrest Drive Suite 200
Bryan, Texas 77802

• Consumer reports may include background, employment history, academic and/or professional credentials, military service, credit history, and driving history. The information gathered also may involve a criminal history and/or alcohol or drug use history, if any.

• An investigative consumer report may include information about your character, general reputation, personal characteristics and mode of living that may be obtained by interviews with individuals who may have knowledge concerning any such items of information. This also may include contacts of all listed prior employers to verify your employment history.

• If your employment falls under the federal Department of Transportation (“DOT”) and the Federal Motor Carrier Safety Administration (“FMCSA”), including 49 CFR § 391.23, the report could include your driving, safety inspection and performance history from the FMCSA.

Under the provisions of the Fair Credit Reporting Act (“FCRA”), 15 U.S.C. § 1681 et seq.; FMCSA regulations in the Federal Code of Regulations, including 49 CFR § 40.329; and certain state laws, before we can seek such reports, where permitted, we must have your written permission to obtain the information.

You have the right, upon written request, to a complete and accurate disclosure of the nature and scope of the investigation. You also are entitled to a copy of that document entitled “Rights Under the Fair Credit Reporting Act”. Under the FCRA, before we take adverse action on the basis, in whole or in part, of information in a consumer report, you will be provided a copy of that report, the name, address, and telephone number of the consumer reporting agency, and a summary of your rights under the FCRA.

• Notice to California Applicants: Under California law, the reports ordered about you for employment purposes within the State of California are defined as “investigative consumer reports.” These reports may contain information on your character, general reputation, personal characteristics and mode of living. Under California Civil Code § 1786.22, you may view the report(s) maintained at iiX during normal business hours. You also may obtain a copy by submitting proper identification and paying the cost of duplication by appearing at iiX in person, by mail, or by telephone. iiX is required to have personnel available to explain the report(s) and to explain any coded information. If you appear in person, you may be accompanied by a person of your choice, if s/he furnishes proper identification.

• Notice to Massachusetts Applicants: Under Massachusetts law, an employer is prohibited from making written, pre-employment inquiries of an applicant about his or her criminal history. MASSACHUSETTS APPLICANTS SHOULD NOT RESPOND TO ANY OF THE QUESTIONS SEEKING CRIMINAL RECORD INFORMATION.


AUTHORIZATION TO OBTAIN INFORMATION

FIRST RIVER ENERGY

I have read and understood the preceding Disclosure to Consumer. Under the Fair Credit Reporting Act (“FCRA”), 15 U.S.C. § 1681 et seq., the regulations applicable to the federal Department of Transportation’s Federal Motor Carriers Safety Administration, including 49 CFR § 40.329, the Americans with Disabilities Act and all other applicable federal, state, and local laws, I hereby authorize and permit the above named company to obtain information about me, where permitted, which may pertain to my employment records, driving history records, driving performance and safety history, criminal history, credit history, civil records, workers’ compensation (post-offer only), alcohol and drug testing, verification of my academic and/or professional credentials, and information and/or copies of documents from any military service records.

I understand an “investigative consumer report” may include information as to my character, general reputation, personal characteristics, and mode of living that may be obtained by interviews with individuals who may have knowledge concerning any such items of information. I authorize information to be obtained from my former employers to satisfy driver qualification regulations.

DOT Drivers. I understand that Title 49 of the Federal Code of Regulations, § 391.23, requires that my prospective employer and/or its agent(s) may contact all former employers of a driver within the last three years under the regulation of the Department of Transportation. Information such as dates of employment, position, accident history, as well as information pertaining to my drug and alcohol testing history, may be requested from each employer in accordance with Section 391.23 and 49 CFR 40.25.

By signing below, I consent to and authorize the gathering of this information by my prospective employer or employer and those who my prospective employer or employer has engaged to request and obtain this information including former employers, and/or from or through a consumer reporting agency, such as iiX, a Verisk Analytics Business.

I understand and acknowledge that the information provided in the consumer reports or investigative consumer reports may assist my employer or prospective employer to make a determination regarding my suitability as an employee.
I further understand that, under the FCRA, in the event of Adverse Action, I may request a copy of any consumer report from the consumer reporting agency that compiled the report, after I have provided proper identification.

I agree that a copy of this authorization has the same effect as an original. Where permitted, this authorization shall remain in effect over the course of my employment and reports may be ordered periodically during the course of my employment.


Para información en español, visite www.ftc.gov/credit o escribe a la FTC Consumer Response Center, Room 130-A 600 Pennsylvania Ave. N.W., Washington, D.C. 20580.

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.ftc.gov/credit or write to: Consumer Response Center, Room 130-A, Federal Trade Commission, 600 Pennsylvania Ave. N.W., Washington, D.C. 20580.

• 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 identity 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, by September 2005 all consumers will be entitled to one free disclosure every 12 months upon request from each nationwide credit bureau and from nationwide specialty consumer reporting agencies. See www.ftc.gov/credit for additional information.

• You have the right to ask for a credit score. Credit 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.ftc.gov/credit 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.ftc.gov/credit.

• 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 1-888-5-OPTOUT (1-888-567-8688).

• You may seek damages from violators. If a consumer reporting agency, or, in some cases, a user of consumer reports 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.ftc.gov/credit.

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. Federal enforcers are:

TYPE OF BUSINESS CONTACT

Consumer reporting agencies, creditors and others not listed below

Federal Trade Commission:
Consumer Response Center - FCRA Washington, DC 20580
877-382-4357

National banks, federal branches/agencies of foreign banks (word "National" or initials "N.A." appear in or after bank's name)

Office of the Comptroller of the Currency
Compliance Management, Mail Stop 6-6 Washington, DC 20219
800-613-6743

Federal Reserve System member banks (except national banks, and federal branches/agencies of foreign banks)

Federal Reserve Consumer Help (FRCH) P O Box 1200
Minneapolis, MN 55480
Telephone: 888-851-1920
Website Address: www.federalreserveconsumerhelp.gov
Email Address: ConsumerHelp@FederalReserve.gov

Savings associations and federally chartered savings banks (word "Federal" or initials "F.S.B." appear in federal institution's name)

Office of Thrift Supervision
Consumer Complaints Washington, DC 20552
800-842-6929

Federal credit unions (words "Federal Credit Union" appear in institution's name)

National Credit Union Administration
1775 Duke Street Alexandria, VA 22314
703-519-4600

State-chartered banks that are not members of the Federal Reserve System

Federal Deposit Insurance Corporation
Consumer Response Center, 2345 Grand Avenue, Suite 100
Kansas City, MO 64108-2638
877-275-3342

Air, surface, or rail common carriers regulated by former Civil Aeronautics Board or Interstate Commerce Commission

Department of Transportation,
Office of Financial Management Washington, DC 20590
202-366-1306

Activities subject to the Packers and Stockyards Act, 1921

Department of Agriculture
Office of Deputy Administrator - GIPSA Washington, DC 20250
202-720-7051


Additional Comments

I certify that the facts contained in this application are true and complete to the best of my knowledge. I understand that any false statement, omission, or misrepresentation in this application is sufficient cause for refusal to hire or dismissal if I have been hired regardless of date of discovery by First River Energy, LLC. and its subsidiaries (the Company). I authorize the company to thoroughly investigate all statements contained in this application or resume, and I authorize my former employers to disclose information regarding my former employment, character and general reputation with them to the Company without giving me prior notice to such disclosure. In addition, I release the Company and any former employers from any claims, demands, or liabilities arising out of or related to such investigation and/or disclosure. I understand and agree that nothing contained in this application, or conveyed during any interview, is intended to create any employment contract. I further understand and agree that if I am hired any employment will be “AT WILL” and without fixed term and may be terminated at any time, with or without cause and without prior notice, at the option of either myself or the Company. No promises regarding employment have been made to me and I understand that no such promise or guarantee is binding upon the Company unless made in writing. I understand that completion of this application does not indicate employment availability and does not obligate the Company to hire me. I agree to adhere to all Company work rules, policies and procedures. First River Energy, LLC. and its subsidiaries reserve the right to revise its policies or procedures, in whole or in part at any time.

When the application for employment is submitted by mail, telephone, computer, or other similar means, if the Company uses any information it obtains from a consumer reporting agency, including FMCSA, in a decision to not hire you or to make any other adverse employment decision regarding you, the Company 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 a consumer reporting agency; the name, address, and the toll free telephone number of consumer reporting agency; that the consumer reporting agency 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 consumer reporting agency the accuracy or completeness of any information or report. If you request a copy of any consumer report from the Company who procured the report, then, within 3 business days of receiving your request, together with proper identification, the Company must send or provide to you a copy of your report and a summary of your rights under the Fair Credit Reporting Act.

First River Energy, LLC. and its subsidiaries does not discriminate in hiring or employment on the basis of race, color, creed, national origin, sex, age, sexual orientation, disability, or status as a disabled veteran or a veteran of the Vietnam Era, or any basis prohibited by state or federal law. No question on your application is intended to secure information used for such discrimination. All applicants and employees will be treated equally in conformity with all existing laws.

I HAVE READ AND UNDERSTOOD THIS AGREEMENT AND BY MY ELECTRONIC SIGNATURE BELOW INDICATE MY ACCEPTANCE OF THIS AGREEMENT AND AUTHORIZE ANY BACKGROUND REPORTS THAT MAY BE REQUESTED BY OR ON BEHALF OF THE COMPANY.


(Type your full name)