Houser Transport, Inc.
POB 148
Vale, NC 28168

I hereby certify that all information on this form is correct and complete to the best of my knowledge. I hereby authorize Impact Transportation Solutions, Inc.,. to do a complete background investigation in accordance with state and federal laws. I authorize release of any information, including all information related to my alcohol and controlled substances testing and training records required by the Federal Highway Administration (FHWA) 49 CFR Parts 391 or 382, by any past or current employers. I hereby release all such persons from any liability or damages. I consent to the procurement and use of any consumer reports, including reports from DAC Services, Inc., deemed necessary by Impact or its subsidiaries in their consideration of my employment.

I understand that I have the right to review information provided by previous employers, have errors corrected by previous employer and resubmitted to Impact and/or have a rebuttal statement attached to erroneous information if my previous employer and I cannot agree on the accuracy of the information.  I understand that I must request past employer information obtained by Impact in writing within 30-days of employment or denial of employment.

ADVERTING SOURCE, CHECK ONLY ONE:

Newspaper Driver Trade Magazine

Name: Date of Birth:

Social Security # Phone:

Street Address:

City: State: Zip Code: E-Mail:

License #: State: Endorsements: Hazmat

Tickets in last 3 years?

Accidents in last 3 years?

Have you worked for this company before?

Are you a US Citizen?

If no, do you have a legal right to live and work in the U.S.?

Have you ever tested positive or refused to test on any pre-employment Drug or Alcohol test administered by an employer to which you applied for, but did not obtain employment during the past three years?

Current/Most Recent Employer: 

Name of Employer: Phone:

Are you presently employed: May we call your current employer:

Address: City: State: Zip code:

Position Held: From: To:

Why do you want to change employers:

 

Were you subject to FMCSR's?

Was your job designated as a Safety Sensitive function in any DOT regulated mode subject to drug and alcohol testing as required by 49 CFR part 40?

Second Last Employer: 

Name of Employer: Phone:

Address: City: State: Zip code:

Position Held: From: To:

Why did you quit:

 

Were you subject to FMCSR's?

Was your job designated as a Safety Sensitive function in any DOT regulated mode subject to drug and alcohol testing as required by 49 CFR part 40?

Third Last Employer: 

Name of Employer: Phone:

Address: City: State: Zip code:

Position Held: From: To:

Why did you quit:

 

Were you subject to FMCSR's?

Was your job designated as a Safety Sensitive function in any DOT regulated mode subject to drug and alcohol testing as required by 49 CFR part 40?