Driver Application

PSA
PlaceSmart Agency
P.O. Box 128
Nashville, IL 62263


Phone: 618-272-2171
Fax: 618-478-2304
www.placesmartagency.com


(First, Middle, Last)







































































































I authorize you to make such investigations and inquiries of 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, scholls, health care providers and other persons from all liability in responding to inquiries and releasing information in connection with my application.

I understand information I provide regarding current and/or previous employers may be used, and those employers will be contacted, for the purpose of investingating 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 the 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.

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




In accordance with the provisions of Section 604 (b)(2)(A) of the Fair Credit Reporting Act, Public Law 91-508, as amended by the Consumer Credit Reporting Act of 1996 (Title II, Subtitle D, Chapter I, of Public Law 104-208), you are being informed that reports verifying your previous employment, previous drug and alcohol test results, and your driving record may be obtained on you for employment purposes. Your employer may obtain this information from Equifax, TransUnion, Experian or other vendors of information services.




In connection with your application for employment with PlaceSmart Agency, it may obtain one or more reports regarding your credit, driving, and/or criminal background history from a consumer reporting agency and/or other sources. If the Prospective Employer uses any information it obtains from a background report in a decision to not hire you or make any other adverse employment decision regarding you, the Prospective Employer will provide you 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 a background report, the Prospective Employer will notify you that the action has been taken and that the background report was the reason for the action. The Prospective Employer cannot obtain background reports from the consumer reporting agencies or other sources regarding you unless you consent in writing. If you agree that the Prospective Employer may obtain such background reports, please read the following and sign below:

I authorize PlaceSmart Agency 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 experience, skills, and abilities. 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, as well as any reference-related information about me held or known by my former employers, supervisors, and co-workers. In addition, I consent to the release of any information about my education, experience, abilities, or work-related characteristics or traits held or known by other organizations or individuals, including school and educational institutions, professional or business associates, and friends and acquintances that Prospective Employer might contact in the course of conducting a reference check or background investigation of my suitability for employment.

I understand and acknowledge that this release of information can involve my qualifications, performance, credentials, or other characteristics or factors affecting my suitability for employment with Prospective Employer. Specifically, I am authorizing the release of any information about my performance, experience, capability, attitude, specific events, or other work-related characteristics that currently are in the possession of the requested organizations or their managers or representatives.

In exchange for Prospective Employer’s consideration of my employment application, I agree not to file or pursue any complaints, claims, or legal actions of any kind against any organization or individual that provides work-related information about me to Prospective Employer or its agents in accordance with the terms and intent of this release. I also agree not to file or pursue any complaints, claims, or legal actions against Prospective Employer or any of its employees, representatives, or agents arising out of their efforts to obtain work-related information about me.

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 and/or any entiry it retainsto obtain such background reports and may obtain reports of my credit, driving, and/or criminal background history in addition to information regarding my background, references, education, specific events, and past employment.

I hereby authorize Prospective Employer and its employees, agents, its affiliates to obtain the information authorized above.



Please Enter the words below and click Submit Application