Non-Drivers Application

I hereby authorize Altom Transport, Inc. and all of their agents (Driver IQ) to request and receive any information and records concerning me, including but not limited to consumer credit, criminal record history, worker’s comp., driving, employment, military, civil and educational data and reports, from any individuals, corporations, parmerships, associations, institutions, schools, governmental agencies and departments, courts, law enforcement and licensing agencies, consumer reporting agencies and other entities, including my present and previous employers.

I further release and discharge Altom Transport, Inc., all of their agents (Driver IQ) and all of its subsidiaries and affiliates, and every employee or agent of any of them, and all individuals and personal, business, private or public entities of any kind, from any and all claims and liability arising out of any request(s) for, or receipt of, information or records pursuant to this authorization, or arising out of any compliance, or attempted compliance, with such request(s). I also authorize the procurement of an investigative consumer report and understand that it may contain information about my character, general reputation, personal characteristics, and mode of living, whichever are applicable. I understand that I have the right to make a written request within a reasonable period of time to Driver IQ, for a complete and accurate disclosure of additional information concerning the nature and scope of the investigation. I further understand that Driver IQ’s reporting of information pursuant to the Fair Credit Reporting Act is not intended to authorize or condone a prospective employer's request for and reliance upon information for purposes which are not legitimate under the Fair Credit Reporting Act or any federal or state employment laws. I acknowledge that I have voluntarily provided the above information for employment purposes, and I have carefully read and I understand this authorization.

This certifies that I prepared this application and that all information is true and complete. I authorize you to make investigations as to my employment, medical, financial, and other related matters necessary to make an employment decision. I hereby release anyone responding to these investigations of all liability related to the release of such information. I understand that false and misleading information in this application and interview(s) is cause for dismissal. If hired, I agree to abide by all lawful rules and regulations of the company.

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

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

Last Updated 12/22/2015

Altom Transport, Inc., 1646 Summer St, Hammond, IN 46320