Grocery Haulers, Inc. [Driver Application]

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Summary of Rights under the Fair Credit Reporting Act:  Open
NY_Correction_Law_Article_23-A:  Open

[New York] Driver Application Form!


We are an Equal Opportunity Employer that does not discriminate in employment because of race, color, creed, age, sex, national origin, physical or mental handicap, ancestry, marital status, affectional or sexual orientation, military service, or any other characteristic protected by the law. Grocery Haulers, Inc.. will endeavor to make reasonable accommodation to the physical or mental limitations of a qualified applicant with a disability unless the accommodation would impose an undue hardship to operation of the business. If you require assistance to complete this form or to participate in an interview please let us know.

Please answer the following questions. We may check with your last employer to inquire as to your safety performance history as required by FMCSA Safety Regulations parts 391.21 and 391.23.

Note: fields marked with "(*)" are required.      

       First Name(*)  Last Name(*)

Street Address(*)

                 City(*)           State(*)  Zip Code: 

  Date of Birth(*)

  Home Telephone:     Cell Phone :          Email: 

Do you have your double endorsement?(*):

If you have double endorsement, is it active?(*):

List States and Counties of Residence for the past 7 years:

  State:   City/County:   From:   To: 

  State:   City/County:   From:   To: 

  State:   City/County:   From:   To: 

  State:   City/County:   From:   To: 

  State:   City/County:   From:   To: 

Position Applied for:

 Type of employment desired:(*)         If employed when can you start?  

 Work location(s) desired:(*)                

    Rate of Pay expected? 

  How did you learn about this position?   

  If you were referred by a current employee, please note the employee's name:   

  Are you age 23 or over?: (*)

  Are you legally authorized to work in United States?: (*)

  Pursuant to the immigration reform act of 1986, all applicants, who are offered employment must produce documents establishing their identity and authorization for employment in the United States. These documents must be produced prior to employment. You will be required to sign Form I-9 (Issued by the federal government) verifying, under oath, your employment authorization.

Have you ever applied for or been employed previously by this company or any of its affiliates?:

    If yes, when:      To   

    Position:      Why did you leave?   

Have you tested positive, or refused to test on any pre-employment drug and/or alcohol test administered by an employer to which you applied to but did not obtain safety sensitive work covered by FMCSA drug testing rules duing the past two years?(*):

U.S. Military(*):

    Branch of U.S. Military Service:     Rank, Classification:  
                                        From:     To:  

Describe any job related training, which will help you perform the duties for the position that you are seeking:

Driver Experience and Qualifications. List all Driver Licenses held in the last 10 years

Driver Licenses:

State Issued(*)  License No(*)  Vehicle Type: 

Expiration Date: 

      State Issued:   License No:       Vehicle Type: 

Expiration Date: 

A. Have you ever been denied a license, permit or privilege to operate a motor vehicle?(*)

B. Has any license, permit or privilege ever been suspended or revoked?(*)

If the answer for either "A" or "B" is yes, please give the details:

Driving Experience:

Type:   Years Driven:   Approx. Miles Driven: 

Type:   Years Driven:   Approx. Miles Driven: 

Last Employers: List employers in reverse order starting with the most recent. (click button "Add Employer" for additional jobs)

  Employer1 Name:  

              Address:  

      Position Held:     From:   To:   Salary:  

  Reason for leaving(*): 

  Employer2 Name: 

                Address: 

        Position Held:    From:    To:   Salary: 

  Reason for leaving(*): 

  Employer3 Name:  

                Address: 

         Position Held:    From:     To:     Salary: 

  Reason for leaving(*): 

  Employer 4 Name:  

              Address:  

      Position Held:     From:   To:   Salary:  

  Reason for leaving(*): 

  Employer 5 Name: 

                Address: 

        Position Held:    From:    To:   Salary: 

  Reason for leaving(*): 

  Employer 6 Name:  

                Address: 

         Position Held:    From:     To:     Salary: 

  Reason for leaving(*): 

Were all of the above jobs subject to FMCSA Safety Regulations? If not, indicate any FMCSA regulated jobs in the employer name fields above. (*):

Tickets or Accidents within last three years?(*):

Explain: 

Have you ever been convicted of or plead guilty to a crime or any other offense, or have any pending criminal charge against you, other than a traffic violation, which has not been expunged or sealed by a court?(*)

A criminal conviction will not necessarily be a bar to employment. To help us evaluate your application, please describe the date of the offense(s), the nature of the offense(s) and your subsequent rehabilitation.

Date(s) of Offense(s)(*):
 

Give Details, including City & State(*):
 

Initial Conditions of Employment

I have read and fully understand the questions asked in this application. I certify that all the answers given by me are true, accurate, and complete. I understand that the omission and/or misrepresentation of any facts from this application or during an interview could result in immediate rejection of my application or if I am hired may be cause for immediate dismissal. I hereby release Grocery Haulers, Inc., and all affiliated entities, as well as any Investigative Firm, Company, Person or institution that provides Grocery Haulers, Inc.., management with any information about me, from any and all liability whatsoever resulting from any such inquiry, investigation or communication.

If hired, I agree to abide by the rules and regulations of Grocery Haulers, Inc.. I understand and agree that nothing in this application shall constitute an offer, a contract or a guarantee of employment for a specific period of time. If hired, I understand that any employment will be on an introductory basis of at least 90 days and that my employment may be terminated with or without cause and with or without notice at any time, at the will of Grocery Haulers, Inc.., and me. I further understand that no representative or agent of Grocery Haulers, Inc.., other than the President of the Company has authority to enter into any agreement for employment for any specific period of time, or to make an agreement contrary to the foregoing unless the agreement is in writing. In addition, I understand that Grocery Haulers, Inc.., and all plan administrators shall have the maximum discretion permitted by law to administer, interpret, modify, discontinue, enhance or otherwise change polices, procedures, benefits or other terms and conditions of employment.

For employment purpose, I authorize Grocery Haulers, Inc.. and any of its authorized agents to conduct a background investigation which may encompass one or more of the following areas of interest: past employment, credit, criminal records, education, driving records, bankruptcy proceedings, and civil litigation. I understand that it may be necessary for Grocery Haulers, Inc.. or assigned third parties to obtain records, in connection with my service to Grocery Haulers, Inc..

Substance Abuse, Pre-Placement Drug Free Workplace Policy

I understand that Grocery Haulers, Inc.. has a substance abuse, drug and alcohol free workplace policy that drug and alcohol testing is an integral part of the policy. I understand and agree that as a condition of employment and continued employment I must submit to and satisfactorily pass all drug tests ordered by the Company as detailed in the Company's Drug Free Workplace Policy.

Acknowledge and agree (*):           Today’s Date:   4/18/2014

Please read this statement before signing (checking "Acknowledge and agree") this application

My signature (checking "Acknowledge and agree") above indicates that I have read and agree with the above conditions of employment including drug/alcohol screening as required by Federal Motor Carrier Safety Regulations and/or company policy. I also understand that my previous employers within the last 3 years will be contacted for purposes of investigating my safety performance history information as required by Federal Motor Safety Regulations parts 391.21 & 391.23.

This application will be kept active for 30 days. Thereafter, I will be required to complete a new application for employment.

NEW YORK CORRECTION LAW ARTICLE 23-A

A COPY OF THIS LAW IS BEING PROVIDED TO YOU IN CONJUNCTION WITH OUR ORDERING BACKGROUND REPORTS ON YOU.

New York Bus Code §380-c(b)(2) and 380-g(d)

§750. Definitions. For the purposes of this article, the following terms shall have the following meanings:

(1) “Public agency” means the state or any local subdivision thereof, or any state or local department, agency, board or commission.

(2) “Private employer” means any person, company, corporation, labor organization or association which employs ten or more persons.

(3) “Direct relationship” means that the nature of criminal conduct for which the person was convicted has a direct bearing on his fitness or ability to perform one or more of the duties or responsibilities necessarily related to the license, opportunity, or job in question.

(4) “License” means any certificate, license, permit or grant of permission required by the laws of this state, its political subdivisions or instrumentalities as a condition for the lawful practice of any occupation, employment, trade, vocation, business, or profession. Provided, however, that “license” shall not, for the purposes of this article, include any license or permit to own, possess, carry, or fire any explosive, pistol, handgun, rifle, shotgun, or other firearm.

(5) “Employment” means any occupation, vocation or employment, or any form of vocational or educational training. Provided, however, that ‘employment” shall not, for the purposes of this article, include membership in any law enforcement agency.

§751. Applicability.

The provisions of this article shall apply to any application by any person for a license or employment at any public or private employer, who has previously been convicted of one or more criminal offenses in this state or in any other jurisdiction, and to any license or employment held by any person whose conviction of one or more criminal offenses in this state or in any other jurisdiction preceded such employment or granting of a license, except where a mandatory forfeiture, disability or bar to employment is imposed by law, and has not been removed by an executive pardon, certificate of relief from disabilities or certificate of good conduct. Nothing in this article shall be construed to affect any right an employer may have with respect to an intentional misrepresentation in connection with an application for employment made by a prospective employee or previously made by a current employee.

§752. Unfair discrimination against persons previously convicted of one or more criminal offenses prohibited.

No application for any license or employment, and no employment or license held by an individual, to which the provisions of this article are applicable, shall be denied or acted upon adversely by reason of the individuals having been previously convicted of one or more criminal offenses, or by reason of a finding of lack of ‘good moral character’ when such finding is based upon the fact that the individual has previously been convicted of one or more criminal offenses, unless:

(1) There is a direct relationship between one or more of the previous criminal offenses and the specific license or employment sought or held by the individual; or

(2) the issuance or continuation of the license or the granting or continuation of the employment would involve an unreasonable risk to property or to the safety or welfare of specific individuals or the general public.

§753. Factors to be considered concerning a previous criminal conviction; presumption.

1. In making a determination pursuant to section seven hundred fifty—two of this chapter, the public agency or private employer shall consider the following factors:

(a) The public policy of this state, as expressed in this act, to encourage the licensure and employment of persons previously convicted of one or more criminal offenses.

(b) The specific duties and responsibilities necessarily related to the license or employment sought or held by the person.

(c) The bearing, if any, the criminal offense or offenses for which the person was previously convicted will have on his fitness or ability to perform one or more such duties or responsibilities.

(d) The time which has elapsed since the occurrence of the criminal offense or offenses.

(e) The age of the person at the time of occurrence of the criminal offense or offenses.

(f) The seriousness of the offense or offenses.

(g) Any information produced by the person, or produced on his behalf, in regard to his rehabilitation and good conduct.

(h) The legitimate interest of the public agency or private employer in protecting property, and the safety and welfare of specific individuals or the general public.

2. In making a determination pursuant to section seven hundred fifty—two of this chapter, the public agency or private employer shall also give consideration to a certificate of relief from disabilities or a certificate of good conduct issued to the applicant, which certificate shall create a presumption of rehabilitation in regard to the offense or offenses specified therein.

§754. Written statement upon denial of license or employment.

At the request of any person previously convicted of one or more criminal offenses who has been denied a license or employment, a public agency or private employer shall provide, within thirty days of a request, a written statement setting forth the reasons for such denial.

§755. Enforcement.

1. In relation to actions by public agencies, the provisions of this article shall be enforceable by a proceeding brought pursuant to article seventy—eight of the civil practice law and rules.

2. In relation to actions by private employers, the provisions of this article shall be enforceable by the division of human rights pursuant to the powers and procedures set forth in article fifteen of the executive law, and, concurrently, by the New York city commission on human rights.

CONSUMER DISCLOSURE, AUTHORIZATION TO OBTAIN CONSUMER REPORT AND INVESTIGATIVE CONSUMER REPORT RELEASE

Para information en espanol, visit www.ftc.gov/credit o describe a la FTC Consumer Response Center, Room 130-A 600 Pennsylvania Ave. N.W., Washington, D.C. 20580.

I have received along with this document “A Summary of Your Rights Under the Fair Credit Reporting Act.” I understand that Grocery Haulers, Inc.. and/or an affiliate (the “Company”), may seek to obtain a consumer report and/or engage a consumer reporting agency (“CRA”) to obtain a consumer report about me. The report may consist of any written, oral or other communication of any information by a CRA bearing on my character, general reputation, personal characteristics, or mode of living (including without limitation conviction records, motor vehicle records, references and copies of prior personnel files). I further understand that the report may be used by the Company for the purpose of evaluating me for employment, promotion, reassignment or retention as an employee. I authorize the Company to obtain such a report for the purpose described above and also authorize the CRA to prepare such a report.

If any adverse decision is made which is based entirely or in part on the information contained in the consumer report, I will be told the basis of that decision and given a copy of the report and a summary of my rights in regard thereto. If I have ever filed for bankruptcy, no employment decision will be based solely on this information.

I hereby fully release the Company and any CRA engaged by the Company, 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 a CRA from all claims and damages arising out of or relating to any investigation and/or disclosure of my background for employment purposes. This release is valid for all federal, state, county and local agencies, authorities, previous employers, military services and educational institutions.

The CRA is authorized to disclose all information (other than as prohibited by law) to the Company for the purpose of determining my eligibility for employment, promotion or any other lawful purpose. I agree that such information which the CRA has or obtains, and my employment history if I am hired, may be supplied by the CRA to other companies that subscribe to the CRA. If hired, this authorization shall remain on file and shall serve as ongoing authorization for the procurement of consumer reports at any time during my employment.

Para informacion en espanol, visite www.consumerfinance.gov/learnmore o escribe a la Consumer Financial Protection Bureau, 1700 G Street N.W., Washington, DC 20006.

A Summary of Your Rights Under the Fair Credit Reporting Act

The federal Fair Credit Reporting Act (FCRA) promotes the accuracy, fairness, and privacy of information in the files of consumer reporting agencies. There are many types of consumer reporting agencies, including credit bureaus and specialty agencies (such as agencies that sell information about check writing histories, medical records, and rental history records). Here is a summary of your major rights under the FCRA. For more information, including information about additional rights, go to www.consumerfinance.gov/learnmore or write to: Consumer Financial Protection Bureau, 1700 G Street N.W., Washington, DC 20006.

  • You must be told if information in your file has been used against you. Anyone who uses a credit report or another type of consumer report to deny your application for credit, insurance, or employment – or to take another adverse action against you – must tell you, and must give you the name, address, and phone number of the agency that provided the information.
  • You have the right to know what is in your file. You may request and obtain all the information about you in the files of a consumer reporting agency (your “file disclosure”). You will be required to provide proper identification, which may include your Social Security number. In many cases, the disclosure will be free. You are entitled to a free file disclosure if:
    • a person has taken adverse action against you because of information in your credit report;
    • you are the victim of identify theft and place a fraud alert in your file;
    • your file contains inaccurate information as a result of fraud;
    • you are on public assistance;
    • you are unemployed but expect to apply for employment within 60 days.
    In addition, all consumers are entitled to one free disclosure every 12 months upon request from each nationwide credit bureau and from nationwide specialty consumer reporting agencies. See www.consumerfinance.gov/learnmore for additional information.
  • You have the right to ask for a credit score. Credit scores are numerical summaries of your credit-worthiness based on information from credit bureaus. You may request a credit score from consumer reporting agencies that create scores or distribute scores used in residential real property loans, but you will have to pay for it. In some mortgage transactions, you will receive credit score information for free from the mortgage lender.
  • You have the right to dispute incomplete or inaccurate information. If you identify information in your file that is incomplete or inaccurate, and report it to the consumer reporting agency, the agency must investigate unless your dispute is frivolous. See www.consumerfinance.gov/learnmore for an explanation of dispute procedures.
  • Consumer reporting agencies must correct or delete inaccurate, incomplete, or unverifiable information. Inaccurate, incomplete or unverifiable information must be removed or corrected, usually within 30 days. However, a consumer reporting agency may continue to report information it has verified as accurate.
  • Consumer reporting agencies may not report outdated negative information. In most cases, a consumer reporting agency may not report negative information that is more than seven years old, or bankruptcies that are more than 10 years old.
  • Access to your file is limited. A consumer reporting agency may provide information about you only to people with a valid need – usually to consider an application with a creditor, insurer, employer, landlord, or other business. The FCRA specifies those with a valid need for access.
  • You must give your consent for reports to be provided to employers. A consumer reporting agency may not give out information about you to your employer, or a potential employer, without your written consent given to the employer. Written consent generally is not required in the trucking industry. For more information, go towww.consumerfinance.gov/learnmore
  • You may limit “prescreened” offers of credit and insurance you get based on information in your credit report. Unsolicited “prescreened” offers for credit and insurance must include a toll-free phone number you can call if you choose to remove your name and address from the lists these offers are based on. You may opt-out with the nationwide credit bureaus at 1-888-567-8688.
  • You may seek damages from violators. If a consumer reporting agency, or, in some cases, a user of consumer reports or a furnisher of information to a consumer reporting agency violates the FCRA, you may be able to sue in state or federal court.
  • Identity theft victims and active duty military personnel have additional rights. For more information, visit www.consumerfinance.gov/learnmore.

States may enforce the FCRA, and many states have their own consumer reporting laws. In some cases, you may have more rights under state law. For more information, contact your state or local consumer protection agency or your state Attorney General. For information about your federal rights, contact:

TYPE OF BUSINESS: CONTACT:
1.a. Banks, savings associations, and credit unions with total
assets of over $10 billion and their affiliates.
a. Bureau of Consumer Financial Protection
1700 G Street NW
Washington, DC 20006
b. Such affiliates that are not banks, savings associations, or credit unions also should list, in addition to the Bureau: b. Federal Trade Commission: Consumer Response Center – FCRA
Washington, DC 20580
(877) 382-4357
2. To the extent not included in item 1 above:  
a. National banks, federal savings associations, and federal branches and federal agencies of foreign banks a. Office of the Comptroller of the Currency Customer Assistance Group
1301 McKinney Street, Suite 3450
Houston, TX 77010-9050
b. State member banks, branches and agencies of foreign banks (other than federal branches, federal agencies, and insured state branches of foreign banks), commercial lending companies owned or controlled by foreign banks, and organizations operating under section 25 or 25A of the Federal Reserve Act b. Federal Reserve Consumer Help Center
P.O. Box 1200
Minneapolis, MN 55480
c. Nonmember Insured Banks, Insured State Branches of Foreign Banks, and insured state savings associations c. FDIC Consumer Response Center
1100 Walnut Street, Box #11
Kansas City, MO 64106
d. Federal Credit Unions d. National Credit Union Administration Office of Consumer Protection (OCP) Division of Consumer Compliance and Outreach (DCCO)
1775 Duke Street
Alexandria, VA 22314
3. Air carriers Department of Agriculture
Office of Deputy Administrator - GIPSA
Washington, DC 20250         202-720-7051
4. Creditors Subject to Surface Transportation Board Office of Proceedings, Surface Transportation Board
Department of Transportation
1925 K Street NW
Washington, DC 20423
5. Creditors Subject to Packers and Stockyards Act Nearest Packers and Stockyards Administration area supervisor
6. Small Business Investment Companies Associate Deputy Administrator for Capital Access
United States Small Business Administration
406 Third Street, SW, 8th Floor
Washington, DC 20416
7. Brokers and Dealers Securities and Exchange Commission
100 F St NE
Washington, DC 20549
8. Federal Land Banks, Federal Land Bank Associations, Federal Intermediate Credit Banks, and Production Credit Associations Farm Credit Administration
1501 Farm Credit Drive
McLean, VA 22102-5090
9. Retailers, Finance Companies, and All Other Creditors Not Listed Above FTC Regional Office for region in which the creditor operates or Federal Trade Commission: Consumer Response Center – FCRA
Washington, DC 20580
(877) 382-4357

I have received along with this document “A Summary of Your Rights Under the Fair Credit Reporting Act.” I understand that my prospective employer, Grocery Haulers, Inc.., and/or an affiliate (the “Company”), will seek to obtain a consumer report and/or will engage a consumer reporting agency (“CRA”) to obtain consumer report about me. The report may consist of any written, oral or other communication of any information by a CRA bearing on my credit worthiness, credit standing, credit capacity; character, general reputation, personal characteristics, or mode of living (including without limitation conviction records, motor vehicle records, references and copies of prior personnel files) which is used or expected to be used or collected in whole or in part for the purpose of serving as a factor in establishing my eligibility for employment purposes. I further understand that the report will be used by the Company for the purpose of evaluating me for employment, promotion, reassignment or retention as an employee. I authorize the Company to obtain such a report for the purpose described above and also authorize the CRA to prepare such a report.

If any adverse decision is made which is based entirely or in part on the information contained in the consumer report, I will be told the basis of that decision and given a copy of the report and a summary of my rights in regard thereto. If I have ever filed for bankruptcy, no employment decision will be based solely on this information.

In addition, I hereby fully release any the company and CRA engaged by the Company, 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 a CRA 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, previous employers, military services and educational institutions.

The CRA is authorized to disclose all information 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 the CRA has or obtains, and my employment history if I am hired, may be supplied by the CRA to other companies that subscribe to the CRA. If hired or contracted, this authorization shall remain on file and shall serve as ongoing authorization for the procurement of consumer reports at any time during my employment or contract period.

I certify that I have read and fully understand this release, and I have submitted this release voluntarily and with the knowledge that the information being released could affect my being hired, my employment, or my eligibility for promotion.


IMPORTANT NOTICE REGARDING BACKGROUND REPORTS FROM THE PSP Online Service


In connection with your application to drive a commercial motor vehicle for Grocery Haulers, Inc. or any of its affiliates (“Prospective Motor Carrier”), it may obtain one or more reports regarding your driving, and safety inspection history from the Federal Motor Carrier Safety Administration (FMCSA). If the Prospective Carrier uses any information it obtains from FMCSA in a decision to not engage you or to make any adverse employment decision regarding you, the Prospective Carrier 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 Carrier 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 Carrier cannot obtain background reports from FMCSA unless you consent in writing. If you agree that the Prospective Carrier may obtain such background reports, please read the following and sign below:

I authorize Grocery Haulers, Inc. or any of its affiliates (“Prospective Carrier”) 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 consenting to 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 Carrier to make a determination regarding my suitability as a commercial motor vehicle driver.

I further understand that neither the Prospective Carrier 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 of the data by submitting a request to https://dataqs.fmcsa.dot.gov. If I am challenging 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 have read the above Notice Regarding Background Reports provided to me by Prospective Carrier and I understand that if I sign this consent form, Prospective Carrier may obtain a report of my crash and inspection history. I hereby authorize Prospective Carrier and its employees, authorized agents, and/or affiliates to obtain the information authorized above.

Acknowledge (*):           Today’s Date:   4/18/2014

For purpose of gathering this information, I agree to supply information, which may be required by law enforcement agencies and other entities for positive identification purposes when checking records. It is confidential and will not be used for any other purpose.

    Enter your Social Security # (*): (XXXXXXXX, 9 digits, no dash "-"; It will be encrypted)

Confirm your Social Security # (*): (XXXXXXXX, 9 digits, no dash "-"; It will be encrypted)

   Other last names you have used: 

By submitting this inquiry, I authorize Grocery Haulers, Inc. and/or its agents to conduct a background check as outlined in the Consumer Disclosure Release.

©2010 Grocery Haulers, Inc.. ALL RIGHTS RESERVED