MAX Freight Registration
Fields mark with * are required.

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1. Have you ever been arrested for driving while intoxicated (DWI or DUI)?
2. Have you ever been tested positive for a controlled substance?
3. Have you ever been refused a required drug or alcohol test?
4. Have you ever been convicted of a Misdemeanor?
5. Have you ever been convicted of a Felcony?
6. Have you had any tickets or accidents in the last 5 years?
   
Please list with details
Did you graduate from a truck driving school?  School Name:  
Year:
*1. Have you had any accidents in the past 3 years?
If Yes, list here
*2. Have you had any Out of Service (OOS) violations in the past 3 years?
If Yes, list here

Do We have permission to contact current employer:


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Trailer Type:
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Reason for Leaving:


Employer:
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Trailer Type:
State:
 

Reason for Leaving:


Employer:
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Position
Address:
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Zip:
Phone:
Trailer Type:
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Reason for Leaving:


Employer:
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Position
Address:
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Zip:
Phone:
Trailer Type:
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Reason for Leaving:

Background Reports From the PSP Online Service
In connection with your application for employment with Max Freight Inc., it may obtain one or more reports regarding your driving, and safety inspection history fiom the Federal Motor Carrier Safety Administration (FMCSA). If the Prospective Employer uses any infomiation 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 ofthe report upon which its decision was based and a written summary of your rights under thc'Fair Credit Reporting Act before taking any final adverse action. Ifany 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. The Prospective Employer cannot obtain background reports from FMCSA unless you consent in writing. If you agree that the Prospective Employer may obtain such background reports, please read the following and sign below:

I authorize Max Freight Inc. to access the FMCSA Pre-Employment Screening Program (PSP) system to seek infomation regarding my commercial driving safety record and information regarding my safety inspection history. I understand that I am consenting to the release of safety performance infomation including crash data from the previous tive (5) years and inspection history from the previous three (3) years. I understand and acknowledge that this release of infomtation 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 ofthe data by submitting a request to https?/dataqs.fmcsa.dot.gov. If I am challenging crash or inspection infomation reported by a State, FMCSA cannot change or correct this data. I understand my request will be forwarded bythe DataQs system to the appropriate State for adjudication.

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I, have read the above Notice Regarding Background Reports provided to me by Prospective Employer and I understand that if I sign this consent form, 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 infomation authorized above.

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NOTICE: This form ls made available to monthly account holders by NICT solely for use as an example oftemplate content. NlCl` assumes no legal liability or responsibility for the accuracy, completeness or cunency ofthe infomration disclosed in this example. The intentofthe template example is to illustrate for a monthly account holder an example ofa driver consent form related to PSP, but all montl1ly account holders and third party information providers should consult their own legal counsel with respect to the proper fonnatand content ofthis notice


I certify that I personally completed this application for the purpose of employment and that all information herein is true and correct. I authorize a complete background investigation in accordance with Sections 382, 405, 413, 391, 23 of the Federal Motor Carrier Safety Regulations. I Authorize release of any information, including all information related to my alchohol and controlled substance testing and traiing records, by any former employer and hold them harmless of any liability of release of said information. I also consent to the procurement and use of any consumer reports, including reports from DAC Services, Inc. deemed necessary to be completed for prospective employers or its subsidiaries in consideration of my employment.

By clicking on the check box, I acknowledge that the information provided above is correct.
         

 


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