Information Driver

Driver Application

Driver Application

First Name: clifford

Last Name: nunes

Address: **** ***** **.

City: hughson

State: CA

ZIP Code: 95326

Cell Phone: 209-***-****

Home Phone: 209-***-****

Email Address: ***************@*****.***

Date Of Birth: 12/22/1959

License State: CA

License Number: f8323404

Level Of Experience: SC

Are You A Veteran?: N

Have you used illegal drugs or prescription marijuana in the past 12 months?: Have you ever been employed as a company driver

or independent contractor for C.R. England?: N

Tickets

Have you had any moving violations in the last five years?: N Accidents

Have you had any traffic accidents in the last five years?: N DUIs/DWIs

Have you ever been cited with DUI or DWI?: N

Suspensions/Revocations

Driver Application

Have you ever had your license suspended or revoked?: N In the past 5 years, have you failed or refused a pre-employment drug screen?: N

Felonies

Have you ever been charged with a felony?: N

Misdemeanors

Have you ever been charged with a misdemeanor?: N

Licenses

Have you been to any other truck driving school in the last five years?: N References

Work History

Employer #1:

Start Date: 05/12/2015

End Date:

Employer name: unemployed

Title: n/a

Employer address: 2301 fifth st.

Employer city: hughson

Employer state: CA

Employer zip code: 95326

Employer phone: 209-***-****

May we contact this employer?: Y

Is this your current employer?: No

Reason for leaving:

Driver Application

Disclaimer

DISCLOSURE:

By submitting this application I certify that I personally have completed this application and that all of the information is true and correct. I hereby authorize C.R. England, Inc. and its agents or contractors that receive this application to cause to be conducted, at any time, an investigation of my background for employment purposes, which may include, but is not limited to, any information relating to my character, general reputation, personal characteristics, mode of living, criminal history, driving record, credit history, past work experience, educational background, alcohol or drug test results, or failure to submit to an alcohol or drug test, or any other information about me which may reflect upon my potential for employment gathered from any individual, organization, entity, agency, or other source which may have knowledge concerning any such items of information. If hired or contracted this authorization for the above reports shall remain on file and shall serve as ongoing authorization for C.R. England, Inc to procure consumer reports at any time during my employment or contract period. I have completed this application of my own free will and hold C.R. England, Inc., its agents and contractors harmless for all liability for providing this application for my use. I consent to receiving text (SMS) messages from CR England and/or its affiliates regarding or relating to my application for employment. I have read and understand the job description and certify that I am able to meet the requirements of this position and may be contacted by, which may include, but is not limited to, email contact, phone contact, direct mail contact. EMPLOYMENT VERIFICATION:

I hereby authorize C.R. England, Inc to do a complete background investigation, which includes contacting my past employers regarding my service, character and drug and alcohol test results as per Federal Motor Vehicle § 391.23 and 382.413. My past employers are released from any and all liability, which may result from furnishing such information. I authorize C.R. England to run a consumer report from USIS (DAC) services. These reports may include information concerning driving record, work experience, and motor vehicle reports. DRIVER RIGHTS NOTIFICATION

FMCSA NOTIFICATION OF DRIVER RIGHTS:

In compliance with 49 CFR Part 40 § 391.23 you have certain rights regarding the 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. 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 Driver Application

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. Prospective employers may consider you to have waived your request to review the record.

By entering your name and identifying information above, you are signing this Disclosure, Consent, and Application electronically. You understand and agree that your electronic signature is the legal equivalent of your manual signature, pursuant to the Electronic Signatures in Global and National Commerce Act (E-SIGN) and applicable state law.

Signature:

Name: henry clifford nunes

Timestamp: 2017-05-26 14:41:36 GMT

IP Address: 63.200.101.21

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