INVESTIGATIVE CONSUMER REPORT DISCLOSURE:
In connection with your employment or application for employment (including contract or services) an investigative report and consumer reports, which may contain public record information, may be requested from USIS Commercial Services (“USIS”). These reports may include the following types of information: names and dates of previous employers, reason for termination of employment, work experience, accidents, academic history, professional credentials, drugs/alcohol use, information relating to your character, general reputation, personal characteristics, mode of living, educational background, or any other information about you which may reflect upon your potential for employment gathered from any individual, organization, entity, agency or other source which may have knowledge concerning any such items of information. Such reports may contain public record information concerning your driving record, workers compensation claims, credit, bankruptcy proceedings, criminal records, and etc. from federal, state and other agencies which maintain such records, as well as information from USIS concerning previous driving record requests made by others from such state agencies.
You have the right to receive upon your written request within a reasonable period of time, (not to exceed 30 days) a complete and accurate disclosure of the nature and scope of the investigation requested. You have the right to make a request to USIS, upon proper identification, to request the nature and substance of all information in its files on you at the time of your request, including the sources of information and the recipients of any reports on you that USIS has preciously furnished with in the two‐year period preceding your request. USIS may be contacted by mail at P.O. Box 33181, Tulsa, Oklahoma 74153 or by phone at 800‐381‐0645.
Attached to this request is a written summary of your rights under the Fair Credit Reporting Act (FCRA) as prepared by the Federal Trade Commission.
Pursuant to the Investigative Consumer Report Disclosure shown above, I authorized USIS Commercial Services to prepare a consumer report or investigative consumer report about me for employment purposes. I have been provided a copy of the summary of rights of the consumer pursuant to the Fair Credit Reporting Act (FCRA). I hereby fully release and discharge USIS, their respective affiliates, subsidiaries, directors, officers, employees, agents and attorneys thereof and each of them, and any individual, organization, entity, agency or other source providing information to USIS from all claims and damages arising out of or relating to any investigation of my background for employment purposes. This release is valid for all federal, state, county and local agencies, authorities, precious employers, military services and educational institutions.
USIS is authorized to disclose all information obtained to the requesting entity for the purpose of making a determination as to my eligibility for employment, promotion or any other lawful purpose. I agree that such information which USIS has or obtains, and my employment history if I am hired, may be supplied by USIS to other companies that subscribe to USIS. If hired or contracted, this authorization shall remain on file and shall service as ongoing authorization for the procurement of consumer reports at any time during my employment or contract period.
By signing below, I certify that I have read and fully understand this release, that prior to signing I was given an opportunity to ask questions and have those questions answered to my satisfaction, and that I executed this release voluntarily and with the knowledge that the information being release could affect my being hired, my employment, or my eligibility for promotion.
In accordance with the requirements of 49 CFR §40.25 and §40.331, you are hereby authorized and requested to release to Hanke Trucking Inc. at 765 Hilldale Rd. Slinger, WI. 53086. Any and all information in your possession concerning my participation in a drug and alcohol testing program for a DOT‐regulated employer within three years preceding the date of this request, including information on any:
1.) Alcohol tests with concentration results of 0.04 or greater;
2.) Verified positive drug tests;
3.) Refusals to be tested (including verified adulterated or substituted drug test results);
4.) Other violations of DOT agency drug and alcohol policies;
5.) Documentation of completion of any DOT return‐to‐duty requirements, including follow‐up testing, connected with any previous drug/alcohol violation; and/or
6.) Drug or alcohol information the above‐referenced employer received from any previous employer under applicable DOT regulations.
A photocopy of this release shall be as valid as the original. This authorization shall be valid for one year from the date of signing hereof.
PRE‐EMPLOYMENT TEST DISCLOSURE
- If yes, please provide the following:
Date Format: MM slash DD slash YYYY
- If yes, please provide the following:
BE SURE THAT YOU HAVE LISTED ALL EMPLOYMENT FOR THE PAST 3 YEARS AND DRIVING JOBS FOR THE PAST 10 YEARS!
I understand that, as required by 49 CFR Part 382 and in accordance with company policy, before being qualified by Hanke Trucking, Inc to drive, a sample of my urine will be collected and tested for controlled substances. If the presence of a controlled substance is confirmed, and after conferring with the company’s Medical Review Officer, the test is determined to be positive, I will not be qualified to drive for Hanke Trucking, Inc. I HEREBY AGREE TO SUBMIT TO A URINE TEST WHEN ASKED.
I understand that an MVR report will be obtained for the appropriate agency in each state in which I have held a driver’s license for the past 3 years as required by FMCSR 391.23, and I understand that I have the right to:
- Review information provided by previous employers by submitting a written request to Hanke Trucking, Inc within 30 days after being employed or notified of denial of employment.
- Have errors in the information corrected by previous employers and for the previous employer to re‐send the corrected information to Hanke Trucking, Inc.
- The right to have a rebuttal statement attached to the alleged erroneous information, if the previous employer and I cannot agree on the accuracy of the information.
I HEREBY GIVE YOU PERMISSION TO ORDER THOSE REPORTS.
In addition, I also acknowledge the receipt of Hanke Trucking Inc.’s NOTICE TO APPLICANTS dated October 30, 2004.
THIS CERTIFIES THAT THIS APPLICATION WAS COMPLETED BY ME, AND THAT ALL ENTRIES ON IT AND INFORMATION IN IT IS TRUE AND COMPLETE TO THE BEST OF MY KNOWLEDGE.
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