Address for the past 3 years
Driver's License Information
Enter your start and end dates for the types of equipment listed below:
EMPLOYMENT HISTORY: When applying for a commercial motor vehicle position, you MUST provide all of your last 3 years employment history and MUST provide 10 years employment history for employers for whom you operated a
commercial motor vehicle. (If you have more than 4 employers, list them on another piece of paper and upload them at the end of this form. )
Start with present or most recent employer
ACCIDENT RECORD FOR THE LAST 5 YEARS: List the date, nature, and any injuries that occured in the accident.
READ AND AGREE BELOW:
This certifies that I completed this application and that all entries on it and information in it are true and complete to the best of my knowledge.
I authorize Gray Rock LLC, its affiliated companies and/or their agents to make such investigations and inquires of my personal, employment, financial, and other related matters in accordance with the state and federal laws. I understand that consumer reports may be requested via outside agents and may include but are not limited to previous employer verifications, reason for termination, accidents, driving records, workers compensation claims etc. I further understand that such reports may contain information from federal, state or other agencies. I hereby release employers, schools, healthcare providers, and other persons from all liability in responding to inquires and releasing information in connection with my application.
I authorize the release of information from my DOT regulated drug and alcohol testing records by my previous employers to Gray Rock LLC, it’s affiliated companies, and/or their agents for the past three years, including but not limited to, positive drug tests, pre-employment tests and refusals to be tested.
I understand that in order for Gray Rock LLC to conduct a full query of the FMCSA Commercial Driver's License Drug & Alcohol Clearinghouse for pre-employment purposes I must go online and login to the website and consent to the query request.
I understand and agree that any information provided by me that is found to be false, incomplete, or misrepresented in any respect in Gray Rock’s sole judgement will be cause to cancel further consideration of my application for employment and/or contracting services whenever such discrepancies are discovered. Further, I understand that by requesting this information that no promise of employment and/or contracting service is being made.
BACKGROUND CHECK DISCLOSURES AND AUTHORIZATION FORM
As part of your application for employment or your interest in being a qualified contractor with Gray Rock, LLC, Gray Rock LLC, it’s affiliated companies and/or their agents intend to obtain one or more reports regarding your employment, credit, driving and/or criminal background history from a consumer reporting agency such as, but not limited to, HireRight, Asurint, and or US Information Search. These consumer reports will be used for employment purposes within the meaning of Fair Credit Reporting Act. To the extent you enter into an employment contractual relationship with
Gray Rock, LLC, Gray Rock LLC may periodically obtain updated consumer reports and criminal background screens. Among the reports that may be procured by the company are reports from Pre-Employment Screening Program conducted by the Federal Motor Carrier Safety Administration.
If Gray Rock uses any information it obtains from a background report by a consumer reporting agency as whole or part reason in a decision to not hire you or to make any other adverse action against you, you may obtain a free copy of the consumer report from the consumer reporting agency so long as the report is requested within 60 days of notification of adverse action. You have the right to dispute any incomplete or inaccurate or incomplete information contained in the report furnished by the consumer reporting agency.
This signed Background Check Disclosure and Authorization Form is my authorization and consent for Gray Rock LLC to obtain, to the extent permitted by the law my employment, credit , driving, Pre-employment Screen Program, and/or criminal background history from a consumer reporting agency and other sources for employment and/or contract purposes.
I authorize Gray Rock LLC, its affiliated companies, and or their agencies to contact any organization or individual that I have listed on my employment application or resume or mentioned in job interviews and obtain from them any relevant information about my job qualifications, including my education, experience, skills, performance, credentials, characteristics, attitude, abilities, and involvement in specific events. I understand that I am consenting to the release of any information about my job qualifications held or known by my former employers, supervisors, and co-workers.
Further, I authorize the request of information from various federal and state agencies that maintain records concerning my past activities relating to my driving, criminal, and civil experiences.
In exchange for Gray Rock’s consideration of my application, I agree not to file or pursue any complaints, claims, or legal actions of any kind against any organization or individual that responds to the requests from Gray Rock or its agents for information about me. I also agree not to file or pursue any complaints, claims, or legal actions against Gray Rock or any of its employees, representatives, or agents arising out of their efforts to obtain work-related information about me.
This authorization shall remain on file and shall serve as on-going authorization for the Company to procure consumer and criminal background reports at any time during my employment or contractual relationship and the qualification process with respect thereto. I understand that, upon termination of employment or contract for any reason, this authorization shall be destroyed and of no further effect.
If you have additional information to add, you may upload your file here:
Thank you for applying to Gray Rock! We have received your application and will be contacting you soon!
*** NEW FMCSA REGULATIONS require that we do query online of your previous drug and alcohol tests. You will need a clearinghouse login to provide consent for us to do so. The site is https://clearinghouse.fmcsa.dot.gov/
