Loaders Application

APPLICANT INFORMATION
Today's Date*
MM slash DD slash YYYY
Name*
First Middle Last
Date of Birth*
MM slash DD slash YYYY
Social Security Number*
Current Address*
Street Address Address Line 2 City State ZIP Code
Phone*
In Case of Emergency Notify:*
Previous Address (last 3 years)
Street Address Address Line 2 City State ZIP Code
Previous Address (last 3 years)
Street Address Address Line 2 City State ZIP Code
Are you a citizen of the United States?*
- Yes
- No
If no, are you authorized to work in the U.S.?*
- Yes
- No
Have you ever worked for this company?*
- Yes
- No
If yes, when?*
Have you ever been convicted of a felony?*
- Yes
- No
If yes, please explain:*

EMPLOYMENT
Company
Phone Number
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Job Title
From
MM slash DD slash YYYY
To
MM slash DD slash YYYY
Reason for Leaving
May we contact for a reference?
- Yes
- No
Company
Phone Number
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Job Title
From
MM slash DD slash YYYY
To
MM slash DD slash YYYY
Reason for Leaving
May we contact for a reference?
- Yes
- No

PREVIOUS EMPLOYEE INFORMATION & RELEASE
Name*
First Middle Last
Social Security Number*
Date of Birth*
MM slash DD slash YYYY
Valid Driver’s License No.*
State Issued*
State
I hereby authorize*

to release the following requested information to CDTA, A Part of National Compliance Solutions Inc., 1011 Camino del Rio S #200, San Diego, CA 92108. (888)-908-2381. for the purpose of investigation to qualify me to drive a commercial motor vehicle as required by the U. S. Department of Transportation & Federal Motor Carrier Safety Regulations Parts 382, 391, 392 & 49 CFR Part 40. I understand that information to be released in Section 2 by my previous employer is limited to the following DOT-regulated testing items:

1. Alcohol test with results of 0.04 or higher; 2. Verified positive drug tests; 3. Refusals to be tested; 4. Other violations of DOT agency drug and alcohol testing regulations; 5. Information obtained from previous employers of a drug and alcohol rule violation; 6. Documentation, if any, of completion of the return-to-duty process following a rule violation.
Signature*
Today's Date*
MM slash DD slash YYYY

GENERAL BACKGROUND INFORMATION RELEASE
This information will, in whole or in part, be obtained from CDTA, A Part of National Compliance Solutions Inc., 1011 Camino del Rio S #200, San Diego, CA 92108. (888)-908-2381. These reports will include information as to my work habits, performance and experience along with reasons for termination of past employment from previous employers. Further, I understand that you will be requesting information from various federal, state and other agencies which maintain records concerning my past activities relating to my driving, credit, civil and other experiences as well as notable criminal activity & claims involving me in the files of insurance companies. This release may also be used to obtain worker's compensation and education records.

By signing below, I also acknowledge that I have read and understand the summary of my rights under The Fair Credit Reporting Act. Pub. L. 111-203, H. R. 4173
Signature*
Today's Date*
MM slash DD slash YYYY

PREVIOUS EMPLOYMENT VERIFICATION
I authorize Villa Park Trucking, Inc, and its agents or representatives the right to investigate all references and to secure additional information about my employment background, and information related to my controlled substance and alcohol testing and/or results pursuant to Regulation 49 CFR 391.23d & e. I further authorize VPT and its agents or representatives’ permission to receive consumer reports regarding my employment history, criminal background, and worker compensation claims from third party agencies such as CDTA or other agencies, which may be requested by VPT to provide such information. I hereby release from all liability for damages VPT and its agents or representatives for seeking such information and all other persons, corporations or organizations for furnishing such information:
Name*
First Middle Last
Social Security Number*
Date of Birth*
MM slash DD slash YYYY
Signature*
Today's Date*
MM slash DD slash YYYY

APPLICANT INFORMATION