Test Application

Full Name*

Phone Number*

Email Address*

Position Applying For

USPS

Contract Personnel Questionnaire

Privacy Act Statement: Your information will be used as a basis for an investigation to determine your fitness and suitability for contractual services to the U.S. Postal Service® (USPS®). Collection is authorized by 39 U.S.C. 3061. Providing the information is voluntary, but if not provided you may be denied access to Postal Service premises, denied access to the mail, or denied participation under a USPS contract. We may disclose your information as follows: in relevant legal pro- ceedings; to law enforcement when the USPS or requesting agency becomes aware of a violation of law; to a congressional office at your request; to entities or individuals under contract with USPS; to entities authorized to perform audits; to labor organizations as required by law; to federal, state, local or foreign government agencies regarding personnel matters; to the Equal Employment Opportunity Commission; to the Merit Systems Protection Board or Office of Special Counsel.

Print Your Full Name (Last, First, Middle Name)*

Print Your Mailing Address (Include Apartment/Suite Number)*

City*

State*

Zip Code*

Home Phone*

Work Phone

Social Security Number (SSN)*

Date of Birth*

Place of Birth*

Sex

Male

Female

Dates and Places of Residence. (If actual places of residence differ from the mailing addresses, furnish and identify both. Begin with present residence and go back for the past five years.)

^1.From(MM/YYYY)*

To (MM/YYYY)

Number and Street*

City*

State*

Zip Code*

^2.From(MM/YYYY)

To (MM/YYYY)

Number and Street

City

State

Zip Code

Employment. (List ALL periods of employment for the past five years starting with your present employment. Include dates when unemployed. Give name under which employed if different from name now used.)

^1.From (MM/YYYY)*

To (MM/YYYY)

Employer and Supervisor's Name*

Employer Address*

Occupation*

Reason For Leaving*

^2.From (MM/YYYY)

To (MM/YYYY)

Employer and Supervisor's Name

Employer Address

Occupation

Reason For Leaving

Are you a US citizen?

Yes

Provide Alien Registration Number if not a United States Citizen

Selective Service Record

Military Service (Past or Present).

Yes

Service Start

Service End

Branch of Service

Serial Number

Authorization and Release - Background Investigation (USPS Contractors and Employees of Contractors)

Applicant: Carefully read the following information before you complete and sign this form.

Privacy Act Statement: The collection of this information is authorized by 39 USC 404, 18 USC 3061, and 5 USC, App. 3. This authorization will be used to obtain information from organizations and individuals pertaining to your character, personal history, credit standing, educational claims, current or prior employment, military service, and other information which may be relevant and necessary to determine your fitness and suitability to perform services under contract with the Postal Service, including a secuirty clearance and evaluation of your loalty to the United States. This authorization does not consent to the collection of information by the Postal Service except as otherwise permitted by law. Nor does it waive any remedy you may have against the Postal Service in the event of a violation of the privacy Act or other rights estabilished by law. As a routine use, this information may disclosed to an agency for which information is requested in the course of a background check; to an appropriate government agency, domestic or foreign, for law enforcement purposes; where pertinent, in a legal proceeding in which the USPS is a party or has an interest; to a government agency in order to obtain information relevant to a USPS decision concerning employment, secuirty clearances, contracts, licenses, grants, permits or other benefits; to a government agency upon its request when relevant to its decision concerning employment, security clearances, security or suitability investigations, contracts, licenses, grants or other benefits; to a congressional office at your request; to an expert, consultant, or other person under contract with the USPS to fulfill an agency function; to the Federal Records Center for Storage; to the Office of Management and Budget for review of private relief legislation; to an independent certified public accountant during an official audit of USPS finances; to an investigator, administrative judges or complaints examiner appointed by the Equal Employment Opportunity Commission for investigation of a formal EEO compliant under 29 CFR 1614; to the Merit Stystems Protection Board or Office of Special Counsel for proceedings or investigations involving personnel practices and other matters within their jurisdiction; and to a labor organization as required by the National Labor Relations Act; to an appropriate foreign or international law enforcement agency, an organization, or individual for investigative or prosecutorial purposes, to assist in cirme prvention or dection, to obtain information relating to a pending investigation, trial or hearing, to obtain the cooperation of a witness or informant or to notify of the statu of the case; to a party or his attorney to discuss settlement, plea bargaining, or discovery proceedings; to an agency or individual concerned with maintenance, extradition, or release of a person held in custody; to a foreign country pursuant to an international treaty, conventions, or executive agreement; to the public, news, media trade associations or organized groups if it is information of interest on accomplishments of the Postal Service or its employees; to a foreign country when apprehending and/or returning a fugitive to a jurisdiction seeking return; to American Insurance Aossociation Index System members if it is information relating to accidents or injuries. Completion of this form is voluntary; however, if consent to obtain this information is not given, it may have an adverse effect on your opporunities to perform services under contract with the USPS

Application's Name*

Date of Birth*

Home Phone Number*

Mailing Address*

Date Signed*

Signature*

Request for Check of Driving Record

I hereby authorize you to reales the following information to FSR Trucking Inc. for purpose of investigation as required by Section 391.23 of the Federal Motor Carrier Safety regulations. Your are released from any and all liability which may result from furning such information.

Name of Applicant*

Date of birth*

Current Address*

SSN*

License Number*

State Issued*

Signature*

Date Signed*

Regarding Background Reports from the PSP Online Services

In connection with your application for employment with FSR/PCC (“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 Safety Administration (FMCSA). When the application for employment is summited in person, the Prospective Employer uses any information it obtains from FMCSA in a decision to not hire you or to make 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 summited 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 taking adverse action oral, written or electronic notification: that adverse action has been taken based in whole or in part on information obtain 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 reason why the adverse actions was taken; and that you may, upon providing proper identifications, request a free copy of the report and may dispute with the FMCSA the accuracy or completeness of nay 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 or 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 capacity 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.

Authorization

If you agree that the Prospective Employer may obtain such background report, please read the following and sign below:

I authorize FSR/PCC (“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 http://dataqs.fmcsa.dot.gov. If I challenge crash or inspection information reported by 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 appear and remain, on my PSP report.

I have read the above Disclosure Regarding Background Reports provided to me by the Prospective Employers and I understand that if I sign this Disclosure and Authorization, Prospective Employer may obtain a record 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.

Date*

Signature*

Name (Print)*

Notice: This form is made available to monthly account holders by NIC and 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 contained in this Disclosure and Authorization form to obtain and Applicant’s consent. The language must be used in whole, exactly as provide. Further, the language on this form must exist as one stand-alone document. The language may NOT be included with other consent forms or any other language.

NOTICE: The prospective employment concept referenced in the form contemplates the definition of “employee” contained at 49 C.F.R 383.5

Release of Information (From Previous Employer)

To release the following information to: F.S.R. TRUCKING, INC

Applicant's Name*

Applicant's Signature*

Date*

Applicant's SSN or ID Number*

Applicant's Date of Birth*

I confirm that the information I am submitting in this application is accurate

USPS

Contract Personnel Questionnaire

Selective Service Record

Authorization and Release - Background Investigation (USPS Contractors and Employees of Contractors)

Applicant: Carefully read the following information before you complete and sign this form.

Request for Check of Driving Record

Regarding Background Reports from the PSP Online Services

Authorization

Release of Information (From Previous Employer)

Corporate Info

Quick Links

Quick Links

Follow Us