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Print this form as it as your release for us to verify your employment and run your MVR. Please sign and date it and fax it to 413-254-7316. If you have any questions please call 800-397-8132. Thanks!
J A C O B S O N T R A N S P O R T A T I O N C O M P A N Y , INC .
AUTHORIZATION FOR RELEASE
OF INFORMATION FOR EMPLOYMENT PURPOSES
I hereby authorize Jacobson Transportation Company, Inc. and its designated agents and representatives to conduct a comprehensive review of my background causing a consumer report and/or an investigative consumer report to be generated for employment purposes. If hired, I understand that this authorization shall be effective throughout my employment, authorizing the Company to conduct comprehensive background checks at any time during my employment.
I hereby authorize Jacobson Transportation Company, Inc. to do a complete background investigation in accordance with state and federal laws. I authorize the release of any information, including all information related to my alcohol and controlled substances testing and training records conducted under the Federal Highway Administration (FHWA) 49 CFR Parts 40, 382 or 391, by any former employers and hold them harmless of any liability from the release of said information.
I hereby authorize Jacobson Transportation Company, Inc. to conduct an investigation of my accident history for the past 3 years while employed in any position that is safety sensitive as defined by the DOT in Federal Motor Carrier Safety Regulations part 391, 390 and 382. I also authorize Jacobson Transportation, Inc. to perform an inquiry into my driving record for every state in which I have held a vehicle operator�s license or permit in the last 3 years.
I understand that I have the right under FMCSR 391 and 390 to review information provided to Jacobson Transportation Company, Inc. by my previous employers. I also have the right to request that any errors in the provided information is corrected by my previous employer(s) and that the corrected information be resent to Jacobson Transportation, Inc. I have the right to have a written rebuttal statement attached to any erroneous information if my previous employer and myself cannot come to an agreement on the accuracy of any of the provided information.
I understand that the scope of the consumer report/investigative consumer report may include, but is not limited to, the following areas:
Verification of social security number, current and previous
residences, employment history including all personnel
files, education, character references, credit history and
reports, criminal history records from any criminal justice
agency in any or all federal, state or county jurisdictions,
birth records, motor vehicle records to include traffic
citations and registration and any other public records.
I authorize the complete release of these records or data pertaining to me which an individual, company, firm, corporation, or public agency may have. I understand that I must provide my date of birth to adequately complete said screening and acknowledge that my date of birth will not affect any hiring decisions.
I hereby release Jacobson Transportation Company, Inc. and its agents, officials, representatives, or assigned agencies, including officers, employees, or related personnel both individually and collectively, from any and all liability for damages of whatever kind, which may at any time, result to me, my heirs, family or associates because of compliance with this authorization and request to release. You may contact me as indicated below.
Print Name: ________________________________
Signature Date: ____________________________
**** For office purposes**** Please fax back to 413-254-7316
Date sent: ___________________________________
Sent by: _____________________________________