Please enter one address per line. Also indicate length of residency at the end of each address.
This information is required by the US DOT, Section 391.21. Please furnish the addresses at which you resided during the 3 years preceding the date on which the application is submitted.
Driver licences held in the past 3 years must be shown.
NOTICE TO APPLICANT
1. All information submitted will be considered in reviewing my application and is subject to investigation. I hereby authorize HanM Transportation Management Services Ltd. to investigate all statements applicable, except as indicated.
2. I certify that the facts set forth in this employment application are true and complete to the best of my knowledge. I understand that misrepresentation or omission of facts called for is cause for dismissal upon discovery of such information.
3. If accepted for employment, I hereby agree to comply with the rules, regulations and policies of HanM Transportation Management Services Ltd.
4. I am aware that an investigative consumer report may be made in connection with my application for employment. This report may include information as to my character, general reputation, personal habits, and mode of living, obtained from or through personal interview with persons with whom I am acquainted, or those persons who may have knowledge concerning any such items of information.
5. In the event that such an investigative consumer report is procured, upon my written request of HanM Transportation Management Services Ltd., I will be provided with a complete and accurate disclosure of the nature and scope of the investigation conducted.
PRE-EMPLOYMENT SUBSTANCE DETECTION CONSENT
I understand that according to the Pre-employment Substance Detection Program at HanM Transportation Management Services Ltd., I am required to submit a sample of my urine for chemical analysis prior to employment. I understand that this pre-employment substance detection will be conducted by a reputable outside physician and testing agency by a certified laboratory.
I consent freely and voluntarily to this request for a pre-employment urine specimen. I hereby and herewith release HanM Transportation Management Services Ltd., their employees, agents, and contractors from any liability whatsoever arising from this request to furnish a pre-employment urine sample, the testing of the urine sample and decisions made concerning my application for employment or continued employment based upon the results of these tests.
I understand a positive test for controlled substances, based on the urinalysis test, will disqualify me from employment and/or the operation of a commercial motor vehicle for HanM Transportation Management Services Ltd.
I understand that if the substance detection results are positive, I can request a second independent confirmatory test using the same specimen. The cost of this test will be borne by me.
I understand a documented chain of specimen custody exists to ensure the identity and integrity of my sample throughout the collection and testing process. The Medical Review Officer will maintain the results of the urinalysis test. Negative and positive results will be reported to the company.
I understand that if my employment is terminated for any reason with HanM Transportation Management Services Ltd. within 90 days, I am liable for the cost of the urinalysis.
This certifies that 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. I have also read and understand the above Notice to Applicant and the conditions for the Pre-Employment Urinalysis Consent Agreement.