Driver Application Test Page

Date*
MM
DD
YYYY
Resume (Optional)
Employing Company: CDS Transportation
Address: 76 Passan Drive
City, State, Zip: Wilkes-Barre, PA 18702

I authorize you to make such investigations and inquiries of my personal, employment, financial, or medical history and other related matters as may be necessary in arriving at an employment decision. (Generally, inquiries regarding medical history will be made only if and after a conditional offer of employment has been extended.) I hereby release employers, schools, health care providers, and other persons from all liability in responding to inquiries and releasing information in connection with my application.

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

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 that I have the right to:

- Review information provided by previous employers;
- Have errors in the information corrected by previous
employers and for those previous employers to re-send the corrected information to the prospective employer; and
- Have a rebuttal statement attached to the alleged erroneous information, if the previous employer(s) and I cannot agree on the accuracy of the information.

Personal Information
Name*
First Last
SSN*
Date of Birth*
MM
DD
YYYY
Contact
Email Address*
Primary Phone*
Cell Phone
Preferred method of contact
Best time to contact you
Address
Please include all addresses lived at for the past 3 years.
Current Address*
Street Address Address Line 2 City State ZIP Code
Former Address
Street Address Address Line 2 City State ZIP Code
Former Address
Street Address Address Line 2 City State ZIP Code
Yes, I agree to receive information concerning future opportunities or promotions from Valley Distributing & Storage Company by email or other commercial electronic communications.

General information
What position are you applying for?*
Are you legally eligible for employment in the United States?*
- Yes
- No
What is the earliest date you can start?*
MM
DD
YYYY
Are you currently employed?*
- Yes
- No
If "No", what date did your last employment end?*
Date Format: MM slash DD slash YYYY
Have you ever been employed by CDS Transportation?*
- Yes
- No
If "Yes", enter start and end dates, location, position, and reason for leaving:*
Please enter the names of any relatives employed here.
Date Format: MM slash DD slash YYYY
Have you ever been known by any other name?*
- Yes
- No
If "Yes", enter name.*
Date Format: MM slash DD slash YYYY
How did you hear about us?
If "Driver Referral", please enter driver's name.*
If "Other", please explain.*

Driving Experience
For each class of equipment, enter the type of equipment (van, reefer, tank, etc.), start and end dates, and an approximate number of total miles. If no experience in a class, enter "NONE".
Straight Truck*
Tractor and Semi-Trailer*
Tractor - Two Trailers*
Other*
Which safe driving awards do you hold and from whom?
Education History
Highest grade completed:*
List last school attended (name, city, and state):*

License Details
License Number*
Country*
Licensing Authority (State)*
License Expiration*
MM
DD
YYYY
Physical Expiration*
MM
DD
YYYY
Is this your current driver's license?*
- Yes
- No
Is this a commercial driver license?*
- Yes
- No
If "Yes", what is your License Class?*
Endorsements
Hazmat expiration date:
MM
DD
YYYY

Were you ever in the U.S. military?
- Yes
- No
Branch of service?*
Start Date:*
MM
DD
YYYY
End Date:*
MM
DD
YYYY

If you are currently in the military, please enter the current date as the End Date.
Rank at Discharge*
Can you obtain your DD214?
- Yes
- No

Driver Training
Have you attended a driver training school?*
- Yes
- No
Start Date:*
MM
DD
YYYY
End Date:*
MM
DD
YYYY

If you are currently in school, please enter the current date as the End Date.
School Name*
Address*
Street Address Address Line 2 City State ZIP Code
Phone*
Did you graduate?*
- Yes
- No
Were you subject to the Federal Motor Carrier or Transport Canada Safety Regulations while attending this truck school?*
- Yes
- No
Did you perform any safety sensitive functions at this truck school, regulated by DOT, and subject to drug and alcohol testing?*
- Yes
- No
GPA*
Hours of Instruction*
Which of the following skills were trained in your program? (Select all that apply)*

Other Training
Have you attended a school (not related to truck driving) in the last 3 years?*
- Yes
- No
School Name*
Start Date:*
MM
DD
YYYY
End Date:*
MM
DD
YYYY

If you are currently in school, please enter the current date as the End Date.
Address*
Street Address Address Line 2 City State ZIP Code
Phone*
What did you study? (accounting, mechanic, etc.)*
Graduation Date: (leave blank if no graduation)*
MM
DD
YYYY

Unemployment Information
Have you been unemployed at any time within the last 3 years?*
- Yes
- No
Start Date:*
MM
DD
YYYY
End Date:*
MM
DD
YYYY

If you are currently unemployed, please enter the current date as the End Date
Comments

PRE-EMPLOYMENT DRUG SCREENING CONSENT FORM I have voluntarily applied for employment with drug-screening to detect the presence of illegal drugs prior to employment. I understand that I will be considered for employment. I understand I have the right to refuse to submit to the test and understand that there will be no penalty except that I may not be considered for employment. As a consideration of my application to work for CDS Transportation, I agree to undergo a drug screening. I also understand that if the test results are positive, I may not be able to work at that assignment and that I will look only to the licensed laboratory performing the test for any compensation in the event that I feel the test results are wrong.

I hereby release and forever discharge CDS Transportation of and from any and all lawsuits, proceedings, claims or causes of action arising from the test or tests, and from any action or inaction of CDS Transportation based on the results of the testing, or use of such results and related documentation in any administrative or court action.

I understand the meaning of this release and consent form, and I have had the opportunity to raise any questions about it before signing it. My signature on the following page is completely voluntary, without coercion or duress of any kind.

I hereby authorize any physician, laboratory, hospital or medical professional retained by CDS Transportation for drug and/or alcohol screening purposes to conduct such screening and to provide the results to CDS Transportation or any person affiliated and any such person or institution conducting the screening.

IMPORTANT DISCLOSURE REGARDING BACKGROUND REPORTS FROM THE PSP ONLINE SERVICE

In connection with your application for employment with CDS Transportation ("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, of 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 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 inspection, 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 CDS Transportation, ("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 not 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.
Name*
First Last
Date*
IMPORTANT DISCLOSURES, TERMS, AND CONDITIONS TO BE READ AND SIGNED BY APPLICANT

CONSUMER DISCLOSURE AND AUTHORIZATION FORM

CDS Transportation 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 int he 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.

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 may include, but are not limited to: social security number verification; 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 verification (e.g., dates of attendance, degrees obtained); employment history verification (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; education institutions; former employers; personal interview 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 that 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 then job for which you are evaluated.

You may request more information about the nature and scope of any investigative consumer reports by contacting the Company. A summary of your rights under the Fair Credit Reporting Act is also being provided to you.

ADDITIONAL 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 HireRight during normal business hours. You may also obtain a copy of this file, upon submitting proper identification and paying the costs of duplication services, by appearing at 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. 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, 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 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. Below is additional information about New York law.

WASHINGTON STATE: If the Company requests an investigative consumer report, you have the right upon written request made within a reasonable period of tie 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.

AUTHORIZATION 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 on the following page, I consent to the preparation of background reports by CDS Transportation. 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 on the following page, 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.

California, Minnesota or Oklahoma applicants only: Please choose yes below if you would like to receive (whenever you have such right under the applicable state law) a copy of your background report if one is obtained on you by the Company.
I certify that all information provided on this form is true and correct.*
- Yes
- No
Notice: The signature on the next page certifies that this application was completed by me, and that all entries on it and information in it are true to the best of my knowledge and that I accept the terms and conditions stated above. Please click Submit to sign.

Driver Application New

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Personal Information

Contact

Address

General information

Driving Experience

Education History

License Details

Employment History

Driver Training

Other Training

Unemployment Information

FMCSR

Incident Details

IMPORTANT DISCLOSURES, TERMS, AND CONDITIONS TO BE READ AND SIGNED BY APPLICANT

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