Required Signatures

To be read and signed by Applicant

It is agreed and understood that any misrepresentation given on this document shall be considered an act of dishonesty.

It is agreed and understood that the motor carrier or their agents may investigate my background to ascertain any and all information of concern to commercial driving record, whether same is of record or not, and I release the employers and persons named herein from all liability for any damages on account of their furnishing such information.

It is also agreed and understood that under the Fair Credit Reporting Act, Public Law 91-508, I have been told that this investigation may include an investigating consumer report, including information regarding my character, general reputation, personal characteristics, and mode of living.

This certifies that the above information was completed by me, and that all entries on it and information in it are true and complete to the best of my knowledge.

Driver's Rights Pertaining To Release Of Driver Information Under Regulation 391.23

Motor carriers have the responsibility to make the following investigations and inquiries with respect to each driver employed, other than a person who has been a regularly employed driver of the motor carrier for a continuous period which began before January 1, 1971.

• (a)(1) An inquiry into the driver’s driving record during the preceding three years to the appropriate agency of every State in which the driver helda motor vehicle operator’s license or permit during those three years; and,
• (a)(2) An investigation of the driver’s employment record during the preceding three years.
• (b) A copy of the driver record(s) obtained in response to the inquiry or inquiries to each State driver record agency as required must be placed in the Driver Qualification File within 30 days of the date the driver’s employment begins and be retained in compliance with 391.51.
• (c) Replies to the investigations of the driver’s safety performance history must be placed in the Driver Investigation History File within 30 days of the date the driver’s employment begins. This goes into effect after October 29, 2004.
• (d) Prospective motor carrier must investigate the information from all previous employers of the applicant that employed the driver to operate aCMV within the previous three years. This information must cover general driver identification and employment verification information, data elements as specified in 390.15 for accident involving the driver that occurred in the three-year period preceding the date of the employment application, and any accidents the previous employer may wish to provide.
• (e) Prospective motor carrier must investigate the information from all previous DOT regulated employers that employed the driver within the previous three years from the date of the employment application in a safety-sensitive function that required alcohol and controlled substance testing specified by 49 CFR Part 40.

Drivers have the following rights:

1. The right to review information provided by previous employers.
2. The right to have errors in the information corrected by the previous employer and for that previous employer to re-send the corrected information to the prospective employer.
3. The right to have a rebuttal statement attached to the alleged erroneous information, if the previous employer and the driver cannot agree on the accuracy of the information.



Drivers who wish to review previous employer-provided investigative information must submit a written request to the prospective employer when applying or as late as 30 days after employed or being notified of denial of employment. The prospective employer must provide this information to the applicant within five business days of receiving the written request. If the driver has not arranged to pick up or receive the requested records within 30 days of the prospective employer making them available, the prospective motor carrier may consider the driver to have waived his/her request to review the records. Drivers wishing to request correction of erroneous information in records must send the request for the correction to the previous employer that provided the records. After October 29, 2004, the previous employer must either correct and forward the information to the prospective motor carrier employer or notify the driver within 15 days of receiving the driver’s request to correct the data that it does not agree to correct the data.Drivers wishing to rebut information in records must send the rebuttal to the previous employer with instruction to include the rebuttal in thed river’s Safety Performance History.




I acknowledge that I have read and understand the contents of this document.

I give permission to Paul Terry Trucking Co. Inc. to run my "MVR." The details on my "MVR" will be held in the strictest of confidence and will be kept in my personnel file. This letter of permission is valid as long as I am an employee of Paul Terry Trucking Co. Inc.

I hereby provide consent to Paul Terry Trucking Co. Inc. to conduct a limited query of the FMCSA Commercial Driver's License Drug and Alcohol Clearinghouse (Clearinghouse) to determine whether drug or alcohol violation about me exists in Clearinghouse. This will provide consent for Paul Terry Trucking Co. Inc. to conduct an annual query for the duration of employment at Paul Terry Trucking Co. Inc.

I understand that if the limited query conducted by Paul Terry Trucking Co. Inc. indicates that drug or alcohol violation information about me exists in the Clearinghouse, FMCSA will not disclose that information to Paul Terry Trucking Co. Inc. without first obtaining additional specific consent from me.

I further understand that if I refuse to provide consent for Paul Terry Trucking Co. Inc. to conduct a limited query of the Clearinghouse, Paul Terry Trucking Co. Inc. must prohibit me from performing safety-sensitive functions, including driving a commercial motor vehicle, as required by FMCSA's drug and alcohol program regulations.