Driver Application Please enable JavaScript in your browser to complete this form. - Step 1 of 7Name *Address *Address Line 1CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeResidence 3 years or longer *YesNoSSN/SIN *Date of birth *Primary phone *Email *Would you like to receive communication from Amg Logistics Inc via email or other commercial electronic communications?Yes, I agree to receive information concerning future opportunities or promotions from Amg Logistics Inc by email or other commercial electronic communications. Would you like to receive communication from Amg Logistics Inc via text message? YesNoBy participating, you consent to receive text messages sent by an automatic telephone dialing system, which may contain recruiting/advertising messages. Consent to these terms is not a condition of being hired, contracted, or leased. You may opt out at any time by texting STOP to unsubscribe. You also agree that Amg Logistics Inc's service provider receives in real time and logs your text messages with Amg Logistics Inc.NEXTWhat position are you applying for? *Company DriverOwner OperatorFleet OwnerEQUIPMENT (OWNER OPERATORS ONLY)EQUIPMENT DESCRIPTION (TRACTOR):TypeYearMakeModelColorVINWeightMileageFifth Wheel HeightAre you legally eligible for employment in the United States? *YesNoAre you currently employed? *YesNoIf No, what date did your last employment end?Do you read, write, and speak English? *YesNoHave you ever worked for this company before? *YesNoIf Yes, enter start and end dates, location, position, and reason for leaving:Do you have a current TWIC card? *YesNoIf Yes, enter expiration date:Have you ever been known by any other name? *YesNoIf Yes, enter name:How did you hear about us? *Driver ReferralOtherIf "Driver Referral", please enter the driver's name:If "Other", please explainDRIVING EXPERIENCEFor each class of equipment, select years of experience. If no experience in a class, select "None". Straight Truck *NoneLess than a year1-2 years2-3 years3-5 years5+ yearsTractor and Semi-Trailer *NoneLess than a year1-2 years2-3 years3-5 years5+ yearsTractor - Two Trailers *NoneLess than a year1-2 years2-3 years3-5 years5+ yearsOtherPREVIOUSNEXTEMPLOYMENT/UNEMPLOYMENTAt least 3 years of employment history is required. Company *Start date *End date *Company addressAddress Line 1CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeCompany phonePosition heldReason for leavingWere you terminated/discharged/laid off?Is this your current employer? *YesNoMay we contact this employer at this time? *YesNoDid you operate a commercial motor vehicle? *YesNoWere you subject to the Federal Motor Carrier or Transport Canada Safety Regulations while employed/contracted by this employer/contractor? *YesNoDid you perform any safety sensitive functions in this job subject to drug and alcohol testing? *YesNoAreas drivenMiles driven weekly *Pay range (cents/mile)Most common truck drivenMost common trailerTrailer length *Company 2CompanyStart dateEnd dateCompany addressAddress Line 1CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeCompany phonePosition heldReason for leavingWere you terminated/discharged/laid off?Is this your current employer?YesNoMay we contact this employer at this time?YesNoDid you operate a commercial motor vehicle?YesNoWere you subject to the Federal Motor Carrier or Transport Canada Safety Regulations while employed/contracted by this employer/contractor?YesNoDid you perform any safety sensitive functions in this job subject to drug and alcohol testing?YesNoAreas drivenMiles driven weeklyPay range (cents/mile)Most common truck drivenMost common trailerTrailer lengthCompany 3CompanyStart dateEnd dateCompany addressAddress Line 1CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeCompany phonePosition heldReason for leavingWere you terminated/discharged/laid off?Is this your current employer?YesNoMay we contact this employer at this time?YesNoDid you operate a commercial motor vehicle?YesNoWere you subject to the Federal Motor Carrier or Transport Canada Safety Regulations while employed/contracted by this employer/contractor?YesNoDid you perform any safety sensitive functions in this job subject to drug and alcohol testing? YesNoAreas drivenMiles driven weeklyPay range (cents/mile)Most common truck drivenMost common trailerTrailer lengthCompany 4CompanyStart dateEnd dateCompany addressAddress Line 1CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeCompany phonePosition heldReason for leavingWere you terminated/discharged/laid off?Is this your current employer?YesNoMay we contact this employer at this time?YesNoDid you operate a commercial motor vehicle?YesNoWere you subject to the Federal Motor Carrier or Transport Canada Safety Regulations while employed/contracted by this employer/contractor?YesNoDid you perform any safety sensitive functions in this job subject to drug and alcohol testing?YesNoAreas drivenMiles driven weeklyPay range (cents/mile)Most common truck drivenMost common trailerTrailer lengthCompany 5CompanyStart dateEnd dateCompany addressAddress Line 1CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeCompany phonePosition heldReason for leavingWere you terminated/discharged/laid off?Is this your current employer?YesNoMay we contact this employer at this time? YesNoDid you operate a commercial motor vehicle? YesNoWere you subject to the Federal Motor Carrier or Transport Canada Safety Regulations while employed/contracted by this employer/contractor?YesNoDid you perform any safety sensitive functions in this job subject to drug and alcohol testing?YesNoAreas drivenMiles driven weeklyPay range (cents/mile)Most common truck drivenMost common trailerTrailer lengthCompany 6CompanyStart dateEnd dateCompany addressAddress Line 1CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeCompany phonePosition heldReason for leavingWere you terminated/discharged/laid off?Is this your current employer?YesNoMay we contact this employer at this time?YesNoDid you operate a commercial motor vehicle?YesNoWere you subject to the Federal Motor Carrier or Transport Canada Safety Regulations while employed/contracted by this employer/contractor?YesNoDid you perform any safety sensitive functions in this job subject to drug and alcohol testing?YesNoAreas drivenMiles driven weeklyPay range (cents/mile)Most common truck drivenMost common trailerTrailer lengthCompany 7CompanyStart dateEnd dateCompany addressAddress Line 1CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeCompany phonePosition heldReason for leavingWere you terminated/discharged/laid off?Is this your current employer?YesNoMay we contact this employer at this time?YesNoDid you operate a commercial motor vehicle?YesNoWere you subject to the Federal Motor Carrier or Transport Canada Safety Regulations while employed/contracted by this employer/contractor?YesNoDid you perform any safety sensitive functions in this job subject to drug and alcohol testing?YesNoAreas drivenMiles driven weeklyPay range (cents/mile)Most common truck drivenMost common trailerTrailer lengthCompany 8CompanyStart dateEnd dateCompany addressAddress Line 1CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeCompany phonePosition heldReason for leavingWere you terminated/discharged/laid off?Is this your current employer?YesNoMay we contact this employer at this time?YesNoDid you operate a commercial motor vehicle?YesNoWere you subject to the Federal Motor Carrier or Transport Canada Safety Regulations while employed/contracted by this employer/contractor?YesNoDid you perform any safety sensitive functions in this job subject to drug and alcohol testing?YesNoAreas drivenMiles driven weeklyPay range (cents/mile)Most common truck drivenMost common trailerTrailer lengthPREVIOUSNEXTTRUCKING SCHOOLStart dateEnd dateSchoolSchool addressAddress Line 1CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeSchool phoneDid you graduate?Yes NoWere you subject to the Federal Motor Carrier or Transport Canada Safety Regulations while attending this truck school?Yes NoDid you perform any safety sensitive functions at this truck school, regulated by DOT, and subject to drug and alcohol testing?Yes NoGPAHours of instructionBorder crossingYes NoLog BooksYes NoFederal Motor Carrier RegulationsYes NoHazardous materialsYes NoPREVIOUSNEXTFMCSRUnder FMCSR 391.15, are you currently disqualified from driving a commercial motor vehicle? *YesNoHas your license, permit or privilege to drive ever been suspended or revoked for any reason? *YesNoHave you ever been denied a license, permit, or privilege to operate a motor vehicle? *YesNoWithin the past two years, have you tested positive, or refused to test, on a pre-employment drug or alcohol test by an employer to whom you applied, but did not obtain, safety-sensitive transportation work covered by DOT agency drug and alcohol testing rules? *YesNoIn the past three (3) years, have you ever been convicted of any of the following offenses?Driving a commercial motor vehicle with a blood alcohol concentration ("BAC") of .04 percent or more *YesNoDriving under the influence of alcohol, as prescribed by state law *YesNoRefusal to undergo drug and alcohol testing as required by any jurisdiction for the enforcement of Federal Motor Carrier Safety Act regulations *YesNoDriving a commercial motor vehicle under the influence of any 21 C.F.R. 1308.11 Schedule I identified controlled substance, an amphetamine, a narcotic drug, a formulation of an amphetamine, or a derivative of a narcotic drug *YesNoTransportation, possession, or unlawful use of a 21 C.F.R. 1308.11 Schedule I identified controlled substance, amphetamines, narcotic drugs, formulations of an amphetamine, or derivatives of narcotic drugs while you were on duty driving for a motor carrier *YesNoLeaving the scene of an accident while operating a commercial motor vehicle *YesNoOr any other felony involving the use of a commercial motor vehicle *YesNoPREVIOUSNEXTVEHICLE ACCIDENT RECORDWere you involved in any accidents/incidents with any vehicle in the last 5 years (even if not at fault)? *YesNoAccident/Incident 1Type of Accident/IncidentInjuryNon-InjuryDate of Accident/IncidentHazmat Accident/IncidentYesNoWas the vehicle towed away?YesNoCityState/ProvinceWere you in a commercial vehicle?YesNoIf yes, was this a Department of Transportation recordable accident?YesNoWere you at fault?YesNoWere you ticketed?YesNoDescriptionAccident/Incident 2Type of Accident/IncidentInjuryNon-InjuryDate of Accident/IncidentHazmat Accident/IncidentYesNoWas the vehicle towed away?YesNoCityState/ProvinceWere you in a commercial vehicle?YesNoIf yes, was this a Department of Transportation recordable accident?YesNoWere you at fault?YesNoWere you ticketed?YesNoDescriptionAccident/Incident 3Type of Accident/IncidentInjuryNon-InjuryDate of Accident/IncidentHazmat Accident/IncidentYesNoWas the vehicle towed away?YesNoCityState/ProvinceWere you in a commercial vehicle?YesNoIf yes, was this a Department of Transportation recordable accident?YesNoWere you at fault?YesNoWere you ticketed?YesNoDescriptionTRAFFIC CONVICTIONS/VIOLATIONSHave you had any moving violations or traffic convictions in the past 3 years? *YesNoConviction/Violation 1Violation dateCharge/DescriptionViolation State/ProvinceIn commercial vehicle?YesNoFined?YesNoLicense suspended?YesNoLicense Revoked?YesNoPerform community service?YesNoOther penalty?YesNoFine amount (if any)CommentsConviction/Violation 2Violation dateCharge/DescriptionViolation State/ProvinceIn commercial vehicle?YesNoFined?YesNoLicense suspended?YesNoLicense Revoked?YesNoPerform community service?YesNoOther penalty?YesNoFine amount (if any)CommentsConviction/Violation 3Violation dateCharge/DescriptionViolation State/ProvinceIn commercial vehicle?YesNoFined?YesNoLicense suspended?YesNoLicense Revoked?YesNoPerform community service?YesNoOther penalty?YesNoFine amount (if any)CommentsCRIMINAL RECORDHave you ever been convicted of a crime? *YesNoConviction 1 (comment)Conviction 2 (comment)Conviction 3 (comment)Do you have any deferred prosecutions? *YesNoDo you have criminal charges pending? *YesNoHave you ever pled "guilty" to, been convicted of, or pled "no contest" to a felony? *YesNoPled 1 (comment)Pled 2 (comment)Pled 3 (comment)If you have any felony convictions, do you currently hold a minister's permit to enter or exit Canada?YesNoHave you, within the last five years, pled "guilty" to, been convicted of, had prosecution deferred in connection with, or pled "no contest" to a misdemeanor? *YesNoSIGNATURESignature (full name) *Clear SignatureIP addressSignature Date/Time *DateTimePREVIOUSNEXTIMPORTANT DISCLOSURE REGARDING BACKGROUND REPORTS FROM THE PSP ONLINE SERVICE *I (a) acknowledge that I have read and understand the PSP Disclosure and also have been given the opportunity to copy/print it, and (b) agree to use an electronic signature to demonstrate my consent. An electronic signature is as legally binding as an ink signature. In connection with your application for employment with AMG Logistics Inc. (“Prospective Employer”), Prospective Employer, its employees, agents or contractors may obtain one or more reports regarding your driving, and safety inspection history from the Federal Motor Carrier Safety Administration (FMCSA). When the application for employment is submitted in person, if the Prospective Employer uses any information 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 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 Employer will notify you that the action has been taken and that the action was based in part or in whole on this report. When the application for employment is submitted by mail, telephone, computer, or other similar means, if the Prospective Employer uses any information it obtains from FMCSA in a decision to not hire you or to make any other adverse employment decision regarding you, the Prospective Employer must provide you within three business days of taking adverse action oral, written or electronic notification: that adverse action has been taken based in whole or in part on information obtained from FMCSA; the name, address, and the toll free telephone number of FMCSA; that the FMCSA did not make the decision to take the adverse action and is unable to provide you the specific reasons why the adverse action was taken; and that you may, upon providing proper identification, request a free copy of the report and may dispute with the FMCSA the accuracy or completeness of any information or report. If you request a copy of a driver record from the Prospective Employer who procured the report, then, within 3 business days of receiving your request, together with proper identification, the Prospective Employer must send or provide to you a copy of your report and a summary of your rights under the Fair Credit Reporting Act. 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. You may challenge the accuracy of the data by submitting a request to https://dataqs.fmcsa.dot.gov. If you challenge crash or inspection information reported by a State, FMCSA cannot change or correct this data. Your request will be forwarded by the DataQs system to the appropriate State for adjudication. Any crash or inspection in which you were involved will display on your PSP report. Since the PSP report does not report, or assign, or imply fault, it will include all Commercial Motor Vehicle (CMV) crashes where you were a driver or co-driver and where those crashes were reported to FMCSA, regardless of fault. Similarly, all inspections, with or without violations, appear on the PSP report. State citations associated with Federal Motor Carrier Safety Regulations (FMCSR) violations that have been adjudicated by a court of law will also appear, and remain, on a PSP report. The Prospective Employer cannot obtain background reports from FMCSA without your authorization.AUTHORIZATION * I (a) acknowledge that I have read and understand the PSP Authorization and also have been given the opportunity to copy/print it, and (b) agree to use an electronic signature to demonstrate my consent. An electronic signature is as legally binding as an ink signature.If you agree that the Prospective Employer may obtain such background reports, please read the following and sign below: I authorize AMG Logistics Inc. (“Prospective Employer”) 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 authorizing 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 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 of the data by submitting a request to https://dataqs.fmcsa.dot.gov. If I challenge 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 understand that any crash or inspection in which I was involved will display on my PSP report. Since the PSP report does not report, or assign, or imply fault, I acknowledge it will include all CMV crashes where I was a driver or co-driver and where those crashes were reported to FMCSA, regardless of fault. Similarly, I understand all inspections, with or without violations, will appear on my PSP report, and State citations associated with FMCSR violations that have been adjudicated by a court of law will also appear, and remain, on my PSP report. I have read the above Disclosure Regarding Background Reports provided to me by Prospective Employer and I understand that if I sign this Disclosure and Authorization, 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 information authorized above. Printed name *Signature *Clear SignatureSigned date *DISCLOSURE FOR CONSUMER REPORTS * I (a) acknowledge that I have read and understand Disclosure for consumer reports and also have been given the opportunity to copy/print it, and (b) agree to use an electronic signature to demonstrate my consent. An electronic signature is as legally binding as an ink signature.In connection with your employment or owner-operator (independent contractor) application, Amg Logistics Inc may order one or more consumer report(s) (commonly known as "background reports" or "background checks") about you from one or more consumer reporting agencies. If you are hired or engaged as an owner-operator (independent contractor), additional consumer reports may be obtained in connection with and throughout your employment for employment purposes or for the legitimate business purpose of evaluating you as an owner-operator. To the extent allowed by law, the consumer reports may include information concerning your character, general reputation, personal characteristics, mode of living, drug and alcohol test results, motor vehicle records, driving records, criminal history, public court records, employment history (including names and dates of previous employers, reason for termination of employment, work experience, and accidents), social security number validation, education, licensure, or verification of other information supplied by you. Such reports may be obtained from private and public record sources, including sanctions databases, CDLIS (including but not limited to CDLIS Central Site, CDLIS Master Pointer Record data and your driver record from the jurisdiction identified in the CDLIS data, in accordance with applicable state law and the Driver Privacy Protection Act), former employers, public court records, and federal, state, and other government agencies that maintain such records.Printed name *Signature *Clear SignatureName *Address *Address Line 1CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePhone *Social Security Number *Signed date *AUTHORIZATION FOR CONSUMER REPORTS * I (a) acknowledge that I have read and understand Authorization for consumer reports and also have been given the opportunity to copy/print it, and (b) agree to use an electronic signature to demonstrate my consent. An electronic signature is as legally binding as an ink signature.I authorize Amg Logistics Inc to obtain one or more consumer report(s) or investigative consumer report(s) about me. If hired or engaged as an owner-operator (independent contractor), I understand this authorization shall remain on file and shall serve as ongoing authorization for additional consumer reports or investigative consumer reports to be obtained from any consumer reporting agency at any time during my employment or contract period without asking me for authorization again.Printed name *Signature *Clear SignatureName *Address *Address Line 1CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePhone *Social Security Number *Signed date *DISCLOSURE AND AUTHORIZATION UNDER 49 C.F.R. PART 391.23 INCLUDING DOT DRUG AND ALCOHOL INFORMATION * I (a) acknowledge that I have read and understand Disclosure and Authorization under 49 C.F.R. Part 391.23 including DOT Drug and Alcohol Information and also have been given the opportunity to copy/print it, and (b) agree to use an electronic signature to demonstrate my consent. An electronic signature is as legally binding as an ink signature.For purposes of an investigation in accordance with 49 C.F.R. Part 391.23, I authorize my previous employers, contractors (if owner-operator), and trucking schools, as applicable, to release and forward to Amg Logistics Inc ("Company") the following information for the past three (3) years: 1. DOT alcohol and controlled substance information in accordance with Parts 382 and 40 of the Federal Motor Carrier Safety Regulations (49 CFR Part 382 and 49 CFR Part 40, Section 40.25) limited to the following DOT regulated testing items, including pre-employment testing results: (i) alcohol tests with a result of 0.04 or higher; (ii) verified positive drug tests; (iii) refusals to be tested; (iv) other violations of DOT agency drug and alcohol testing regulations; (v) information obtained from previous employers of a drug and alcohol rule violation; and (vi) documentation, if any, of completion of the return-to-duty process following a rule violation. 2. Safety performance history information in accordance with 49 CFR Part 391.23, which includes: employment dates, work history (which may include position held, reason for leaving, any termination information, whether subject to the Federal Motor Carrier Safety Administration regulations, equipment experience, area driven, and other information as applicable) and accident information (including accident date, nature of accident, whether it was preventable, whether there were injuries, fatalities, or hazardous materials involved, and copies of any accident report). Pursuant to Section 391.23(i) of the Federal Motor Carrier Safety Regulations, you have the following rights with regard to the information released: 1. You have the right to make a written request at any time to review the information provided by previous employers, contractors (if owner-operator), or trucking schools, as applicable. 2. You have the right to have errors in the information corrected by the previous employer, contractor (if owner-operator), or trucking school, as applicable and for that employer, contractor (if owner-operator), or trucking school to re-send the corrected information. 3. You have the right to have a rebuttal statement attached to the alleged erroneous information if the previous employer, contractor (if owner-operator), or trucking school and you cannot agree on the accuracy of the information. Printed name *Signature *Clear SignatureName *Address *Address Line 1CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePhone *Social Security Number *Signed date *Authorization for previous employers, contractors (if owner-operator) and trucking schools *I, the above mentioned signer, hereby authorize my previous employers, contractors (if owner-operator), and trucking schools, as applicable to release and forward in accordance with the following regulation, all known information pertaining to my alcohol and controlled substances testing/training records to Amg Logistics Inc.CONSENT FOR LIMTED QUERIES OF THE FEDERAL MOTOR CARRIER SAFETY ADMINISTRATION (FMCSA) DRUG AND ALCOHOL CLEARINGHOUSE *I hereby provide consent to Amg Logistics Inc to conduct a limited query of the FMCSA Commercial Driver's License Drug and Alcohol Clearinghouse to determine whether drug or alcohol violation information about me exists in the Clearinghouse. I understand this consent shall remain on file and shall serve as ongoing consent for Amg Logistics Inc to conduct multiple limited queries of the Clearinghouse at any time during my employment or contract period without asking me for additional consent. I understand that if I refuse to provide consent for Amg Logistics Inc to conduct a limited query of the Clearinghouse, Amg Logistics Inc is required to prohibit me from performing safety-sensitive functions, including operating a commercial motor vehicle. I understand that if the limited query conducted by Amg Logistics Inc indicates that drug or alcohol information exists about me in the Clearinghouse, the FMCSA will not disclose that information to Amg Logistics Inc unless I give additional specific consent within the Clearinghouse. However, I understand that Amg Logistics Inc will be required to conduct a full query of the Clearinghouse within 24 hours after a limited query indicates that drug or alcohol information exists and that if I do not grant consent within the Clearinghouse for that full query I will be removed from performing safety-sensitive functions, including operating a commercial motor vehicle. Printed name *Signature *Clear SignatureSigned date *Federal FCRA Summary of Rights Acknowledgment *I acknowledge that I have read and understand the federal FCRA Summary of Rights and have been given the opportunity to copy/print the Summary of Rights.1681m *I represent that I understand and agree to the document attached below the form.Investigative Consumer Report Disclosure *I represent that I understand and agree to the document attached below the form.Upload front and back side of your CDL * Click or drag files to this area to upload. You can upload up to 2 files. Upload MEDICAL CARD / DOT physical certificate * Click or drag files to this area to upload. You can upload up to 2 files. Upload Social Security card * Click or drag files to this area to upload. You can upload up to 2 files. APPLY READ THE FEDERAL FCRA SUMMARY OF THE RIGHTS ACKNOWLEDGEMENT READ THE 1681M READ THE INVESTIGATIVE CONSUMER REPORT DISCLOSURE