Rock on Trucks Company Drivers Application

Step 1 of 8

Name
Name*
First Middle Last
Maiden Name, if any
Address
Address*
Street Address Address Line 2 City State ZIP Code
How long at current address?*
Years
Personal Information
Date Of Birth*
Month
Day
Year
Social Security Number

Optional
Date Available
MM slash DD slash YYYY
Phone Number*
Previous Three Years Residency
Address*
Street Address Address Line 2 City State ZIP Code
Number of Years*
Add Additional Residency?*
- Yes
- No
Address*
Street Address Address Line 2 City State ZIP Code
Number of Years*
Add Additional Residency?*
- Yes
- No
Address*
Street Address Address Line 2 City State ZIP Code
Number of Years*

To be read and signed by applicant
To be read and signed by applicant
I authorize you to make sure investigations and inquiries to my personal, employment, financial or medical history and other related matters as may be necessary in arriving at an employment decision. (Generally, inquiries regarding medical history will be made only if and after a conditional offer of employment has been extended.) I hereby release employers, schools, health care providers and other persons from all liability in responding to inquiries and releasing information in connection with my application. In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the Company. "I understand that information I provide regarding current and/or previous employers may be used, and those employer(s) will be contacted, for the purpose of investigating my safety performance history as required by 49 CFR 391.23(d) and (e). I understand that I have the right to: Review information provided by current/previous employers; Have errors in the information corrected by previous employers and for those previous employers to re-send the corrected information to the prospective employer; and Have a rebuttal statement attached to the alleged erroneous information, if the previous employer(s) and I cannot agree on the accuracy of the information"
I authorize you to make sure investigations and inquiries to my personal, employment, financial or medical history and other related matters as may be necessary in arriving at an employment decision. (Generally, inquiries regarding medical history will be made only if and after a conditional offer of employment has been extended.) I hereby release employers, schools, health care providers and other persons from all liability in responding to inquiries and releasing information in connection with my application.

In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the Company. "I understand that information I provide regarding current and/or previous employers may be used, and those employer(s) will be contacted, for the purpose of investigating my safety performance history as required by 49 CFR 391.23(d) and (e). I understand that I have the right to:
- Review information provided by current/previous employers;
- Have errors in the information corrected by previous employers and for those previous employers to re-send the corrected information to the prospective employer; and
- Have a rebuttal statement attached to the alleged erroneous information, if the previous employer(s) and I cannot agree on the accuracy of the information"
Date*
Month
Day
Year
Signature*
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.
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.
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.
Date*
Month
Day
Year
Signature*
Note:
A motor carrier may require an applicant to provide information in addition to the information required by the Federal Motor Carrier Safety Regulations.
A motor carrier may require an applicant to provide information in addition to the information required by the Federal Motor Carrier Safety Regulations.

Safety Performance History Records Request
Please provide information for each employer in the previous 3 years.
I,
I,
I,
Name*
First Middle Last
Social Security Number

Optional
Date of Birth*
Month
Day
Year
Hereby authorize:
Hereby authorize:
Hereby authorize:
Previous Employer*
Email*
Phone Number*
Fax Number
Address*
Street Address Address Line 2 City State ZIP Code
To release and forward the information requested concerning my Alcohol and Controlled Substances Testing records within the previous 3 years from
To release and forward the information requested concerning my Alcohol and Controlled Substances Testing records within the previous 3 years from
To release and forward the information requested concerning my Alcohol and Controlled Substances Testing records within the previous 3 years from
Employment Application Date*
MM slash DD slash YYYY
To:
Prospective Employer: Rock On Enterprises Attention: Human Resources Telephone: (320) 257-5539 Street: 3100 7th Street South City, State, Zip: Waite Park, MN 56387 In compliance with §40.25(g) and 391.23(h), release of this information must be made in a written form that ensures confidentiality, such as fax, email, or letter. Prospective employer's fax number: (320) 230-2912 Prospective employer's email address: mollie@rockontrucks.com
Prospective Employer: Rock On Enterprises
Attention: Human Resources
Telephone: (320) 257-5539
Street: 3100 7th Street South
City, State, Zip: Waite Park, MN 56387

In compliance with §40.25(g) and 391.23(h), release of this information must be made in a written form that ensures confidentiality, such as fax, email, or letter.

Prospective employer's fax number: (320) 320-2912
Prospective employer's email address: payables@rockontrucks.com
Applicant's Signature*
Date*
MM slash DD slash YYYY
This information is being requested in compliance with §40.25(g) and 391.23.
This information is being requested in compliance with §40.25(g) and 391.23.
This information is being requested in compliance with §40.25(g) and 391.23.
Add Additional Employer? Part 1*
- Yes
- No
I,
I,
I,
Name*
First Middle Last
Social Security Number

Optional
Date of Birth*
Month
Day
Year
Hereby authorize:
Hereby authorize:
Hereby authorize:
Previous Employer*
Email*
Phone Number*
Fax Number
Address*
Street Address Address Line 2 City State ZIP Code
To release and forward the information requested concerning my Alcohol and Controlled Substances Testing records within the previous 3 years from
To release and forward the information requested concerning my Alcohol and Controlled Substances Testing records within the previous 3 years from
To release and forward the information requested concerning my Alcohol and Controlled Substances Testing records within the previous 3 years from
Employment Application Date*
MM slash DD slash YYYY
To:
Prospective Employer: Rock On Enterprises Attention: Human Resources Telephone: (320) 257-5539 Street: 3100 7th Street South City, State, Zip: Waite Park, MN 56387 In compliance with §40.25(g) and 391.23(h), release of this information must be made in a written form that ensures confidentiality, such as fax, email, or letter. Prospective employer's fax number: (320) 230-2912 Prospective employer's email address: HR@rockontrucks.com
Prospective Employer: Rock On Enterprises
Attention: Human Resources
Telephone: (320) 257-5539
Street: 3100 7th Street South
City, State, Zip: Waite Park, MN 56387

In compliance with §40.25(g) and 391.23(h), release of this information must be made in a written form that ensures confidentiality, such as fax, email, or letter.

Prospective employer's fax number: (320) 230-2912
Prospective employer's email address: payables@rockontrucks.com
Signature*
Date*
MM slash DD slash YYYY
This information is being requested in compliance with §40.25(g) and 391.23.
This information is being requested in compliance with §40.25(g) and 391.23.
This information is being requested in compliance with §40.25(g) and 391.23.
Add Second Additional Employer? Part 1 -2*
- Yes
- No
I,
I,
I,
Name*
First Middle Last
Social Security Number

Optional
Date of Birth*
Month
Day
Year
Hereby authorize:
Hereby authorize:
Hereby authorize:
Previous Employer*
Email*
Phone Number*
Fax Number
Address*
Street Address Address Line 2 City State ZIP Code
To release and forward the information requested concerning my Alcohol and Controlled Substances Testing records within the previous 3 years from
To release and forward the information requested concerning my Alcohol and Controlled Substances Testing records within the previous 3 years from
To release and forward the information requested concerning my Alcohol and Controlled Substances Testing records within the previous 3 years from
Employment Application Date*
MM slash DD slash YYYY
To:
Prospective Employer: Rock On Enterprises Attention: Mollie Parks Telephone: (320) 257-5539 Street: 3100 7th Street South City, State, Zip: Waite Park, MN 56387 In compliance with §40.25(g) and 391.23(h), release of this information must be made in a written form that ensures confidentiality, such as fax, email, or letter. Prospective employer's fax number: (320) 257-5538 Prospective employer's email address: mollie@rockontrucks.com
Prospective Employer: Rock On Enterprises
Attention: Human Resources
Telephone: (320) 257-5539
Street: 3100 7th Street South
City, State, Zip: Waite Park, MN 56387

In compliance with §40.25(g) and 391.23(h), release of this information must be made in a written form that ensures confidentiality, such as fax, email, or letter.

Prospective employer's fax number: (320) 230-2912
Prospective employer's email address: payables@rockontrucks.com
Signature*
Date*
MM slash DD slash YYYY
This information is being requested in compliance with §40.25(g) and 391.23.
This information is being requested in compliance with §40.25(g) and 391.23.
This information is being requested in compliance with §40.25(g) and 391.23.

Mandatory Use For All Account Holders
IMPORTANT NOTICE REGARDING BACKGROUND REPORTS FROM THE PSP Online Service
1. In connection with your application for employment with Rock On Enterprises, 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. The Prospective Employer cannot obtain background reports from FMCSA unless you consent in writing. If you agree that the Prospective Employer may obtain such background reports, please read the following and sign below: 2. I authorize Rock On Enterprises, 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 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 Employer to make a determination regarding my suitability as an employee. 3. 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 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. 4. Please note: 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 FMCSR violations that have been adjudicated by a court of law will also appear, and remain, on a PSP report.
In connection with your application for employment with Rock On Enterprises, 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.
If you agree that the Prospective Employer may obtain such background reports, please read the following and sign below: I authorize Rock On Enterprises, 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.
I have read the above Notice Regarding Background Reports provided to me by Prospective Employer and I understand that if I sign this consent form, 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.
If you agree that the Prospective Employer may obtain such background reports, please read the following and sign below:

I authorize Rock On Enterprises, 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.
Signature*
Name*
Date*
MM slash DD slash YYYY
NOTICE:
This form is made available to monthly account holders by NICT on behalf of the U.S. Department of Transportation, Federal Motor Carrier Safety Administration (FMCSA). Account holders are required by federal law to obtain an Applicant's written or electronic consent prior to accessing the Applicant's PSP report. Further, account holders are required by FMCSA to use the language provided in paragraphs 1-4 of this document to obtain an Applicant's consent. The language must be used in whole, exactly as provided. The language may be included with other consent forms or language at the discretion of the account holder, provided the four paragraphs remain intact and the language is unchanged.
This form is made available to monthly account holders by NICT on behalf of the U.S. Department of Transportation, Federal Motor Carrier Safety Administration (FMCSA). Account holders are required by federal law to obtain an Applicant's written or electronic consent prior to accessing the Applicant's PSP report. Further, account holders are required by FMCSA to use the language provided in paragraphs 1-4 of this document to obtain an Applicant's consent. The language must be used in whole, exactly as provided. The language may be included with other consent forms or language at the discretion of the account holder, provided the four paragraphs remain intact and the language is unchanged.

Request for Check of Driving Record
I hereby authorize you to release the following information to Midwest Compliance Inc. for purposes of investigation as required by Sections §391.23 and §391.25 of the Federal Motor Carrier Safety Regulations. You are released from any and all liability, which may result from furnishing such information.
I hereby authorize you to release the following information to Midwest Compliance Inc. for purposes of investigation as required by Sections §391.23 and §391.25 of the Federal Motor Carrier Safety Regulations. You are released from any and all liability, which may result from furnishing such information.
I hereby authorize you to release the following information to Midwest Compliance Inc. for purposes of investigation as required by Sections §391.23 and §391.25 of the Federal Motor Carrier Safety Regulations. You are released from any and all liability, which may result from furnishing such information.
Name of Applicant/Driver*
Current Address*
Street Address Address Line 2 City State ZIP Code
Former Address*
Street Address Address Line 2 City State ZIP Code
Date of Birth*
Month
Day
Year
Social Security Number

Optional
License #*
Applicant's Signature*
Date*
MM slash DD slash YYYY
In accordance with the provisions of Section 604 and 607 of the Fair Credit Reporting Act Public Law 91-508, I hereby certify the following: 1. The applicant has authorized in writing the procurement of the report; 2. The information requested below will be used for a "permissible purpose" (i.e., information for employment purposes) and will be used for no other purpose; 3. The information being obtained will not be used in violation of any federal or state equal employment opportunity law or regulation and 4. Before taking adverse action based in whole or in part on the report, the applicant will receive a copy of the requested report. I also hereby certify that this report request and the above applicant's release notice meet the definition of "permissible uses" of state motor vehicle records under the provisions of the Driver's Privacy Protection Act of 1994.
In accordance with the provisions of Section 604 and 607 of the Fair Credit Reporting Act Public Law 91-508, I hereby certify the following: 1. The applicant has authorized in writing the procurement of the report; 2. The information requested below will be used for a "permissible purpose" (i.e., information for employment purposes) and will be used for no other purpose; 3. The information being obtained will not be used in violation of any federal or state equal employment opportunity law or regulation and 4. Before taking adverse action based in whole or in part on the report, the applicant will receive a copy of the requested report. I also hereby certify that this report request and the above applicant's release notice meet the definition of "permissible uses" of state motor vehicle records under the provisions of the Driver's Privacy Protection Act of 1994.
In accordance with the provisions of Section 604 and 607 of the Fair Credit Reporting Act Public Law 91-508, I hereby certify the following:
1. 1. The applicant has authorized in writing the procurement of the report;
2. 2. The information requested below will be used for a "permissible purpose" (i.e., information for employment purposes) and will be used for no other purpose;
3. 3. The information being obtained will not be used in violation of any federal or state equal employment opportunity law or regulation and
4. 4. Before taking adverse action based in whole or in part on the report, the applicant will receive a copy of the requested report.
I also hereby certify that this report request and the above applicant's release notice meet the definition of "permissible uses" of state motor vehicle records under the provisions of the Driver's Privacy Protection Act of 1994.
REQUESTED BY
Midwest Compliance INC. 100 2nd Ave South, Suite 104 Sauk Rapids, MN 56379
Midwest Compliance INC.
100 2nd Ave South, Suite 104
Sauk Rapids, MN 56379

Step 1 of 8

Name

Address

Personal Information

Previous Three Years Residency

License Information

Driving Experience

Accident Record For Past 3 Years Or More

Traffic Convictions & Forfeitures Past 3 Years

Employment Record

To be read and signed by applicant

Safety Performance History Records Request

Mandatory Use For All Account Holders

Request for Check of Driving Record

Voluntary Applicant Self-Identification Survey