Health Benefits –
Anthem Blue Access PPO
Prescription Drugs (Network Pharmacy)
Vision Benefits –
Anthem Blue View Vision
Anthem Dental Complete
Life Insurance –
Term and Accidental
7020 Cline Avenue, Hammond, IN 46323
If none, enter NA in first field
Please provide your most recent 3 years of work history or if you have driven a commercial motor vehicle in the last ten years, provide the previous 10 years of work history. List complete mailing address (street number, city, state and zip code). *Includes vehicles having a GVWR of 26,001 lbs. or more, vehicles designed to transport 15 or more passengers, or any size vehicle used to transport hazardous materials in a quantity requiring placarding.
(List employers in reverse order starting with the most recent.)
I understand that nothing contained in the application, or conveyed during any interview which may be granted, if hired/contracted, is intended to create a contract between the Company and me. Company Driver Applicants: I understand that if I am hired, it is not for a specific duration and the relationship may be terminated at will, without advance notice, with or without cause to the fullest extent allowed by law, at any time at the option of either the Company or myself. If hired, I understand that the Company may change any terms of our relationship including, but not limited to, work assignment, schedules, pay levels and/or location. I further understand that no manager, supervisor or representative of the Company other than the Chief Executive Officer has any authority to enter into any agreement contrary to the foregoing. Owner-Operator Applicants: I understand and agree that I am seeking qualification as an independent contractor and that, if qualified, I will not be entering into an employment relationship with IST Logistics. I understand that this request for qualification is not and is not intended to be a contract and that if a contract is entered into, any resulting contractual relationship will be subject to and terminable in accordance with the terms of that fully executed agreement.
I understand and agree to submit to any and all drug and /or alcohol testing and physical exams that may be required by law, regulation and/or company policy prior to and during my employment/contracting relationship. I further specifically acknowledge and understand that pursuant to “pre-employment testing” required by Federal Regulations (unless exempted) I must undergo testing for controlled substances prior to performing safety-sensitive functions, as a condition prior to being used.
I agree to the collection of a urine sample and to controlled substance testing and I acknowledge and understand that pursuant to Federal Regulations, verified negative test results must be obtained and reported to the company prior to a driver performing a safety-sensitive function and that, any positive results will result in the rejection of my request for employment/qualification. My initials indicate that I fully understand and consent to the same.
To the extent applicable, I agree and consent that the Company may inspect any Company property at any time and for any reason, without notice. This property includes, without limitation, work stations, computers, offices, desks, lockers, voice mail, and filing cabinets. Additionally, I agree and consent that any personal items I bring onto Company premises are subject to inspection at any time and for any reason, without prior notice.
To the extent allowed by law, my signature authorizes the Company or its authorized agents to conduct a thorough investigation of all statements, written and oral, made by me during the application and qualification process, including without limitation, information concerning my previous positions, law enforcement record, driving record, and educational background. I hereby authorize all persons, companies or other entities connected with any such informational request, including without limitation, current or prior employers or companies and law enforcement agencies to provide any and all information they may have regarding me. I release and agree to indemnify the Company, its authorized agents, and its employees, and all other persons, companies, and other entities from any and all liability arising out of such investigation, including without limitation, any liability for furnishing information or for taking any action based on the information provided. I authorize references I have listed to disclose to the Company any and all documents or other information related to my work record, without giving me prior notice of such disclosure. In addition, I hereby release the company, my former employers/companies and all other persons, corporations, partnerships and associates from any and all claims, demands or liabilities arising out of or in any way related to such investigation or disclosure.
FOR COMPANY DRIVER APPLICANTS: I understand that after a conditional offer of employment but before beginning employment, I may be required to: furnish proof of my identity and U.S citizenship or proof of my legal right to work in the United States, as required by federal law and that failure to do so and/or lack of proper documentation (within three (3) days of hire) will result in termination pursuant to the Immigration Reform and Control Act of 1986.
I understand that if hired/qualified, I agree to abide by any and all company policies relating to the confidentiality of the Company’s information.
I certify that the information provided on this application is true and correct. I understand that any misrepresentation, false information or omission of facts made in this application or any attachment may disqualify me from further consideration for employment/contracting relationship and if hired or qualified, shall be grounds for termination of that employment or contractual relationship as provided therein. I agree that a photocopy or imaged copy of this signed acknowledgement will be as valid and enforceable as the original.
I have carefully read this application and acknowledgement and fully understand and agree to its contents. I am signing this application voluntarily.
By signing below, I affirm that I have completed the entire application to the best of my ability, have carefully read the foregoing statements, agree to their terms and understand that the Company is relying on any and all of the foregoing representations, promises and releases in considering my application. Any misrepresentations, falsifications or material omissions in any of this information or data may result in the Company’s refusal to consider me for an employment or contract relationship or, if I have been hired/contracted, the termination of that relationship.
FMCSA amends its regulations to allow the use of electronic records and signatures to satisfy FMCSA's regulatory requirements. These amendments permit the use of electronic methods to generate, certify, sign, maintain, or exchange records so long as the documents accurately reflect the required information and can be used for their intended purpose. This rule applies only to those documents that FMCSA's regulations obligate entities or individuals to retain; it does not apply to forms or other documents that must be submitted directly to FMCSA unless there are already procedures in place in the regulations for electronic submission to FMCSA. This rule partially implements the Government Paperwork Elimination Act (GPEA) and the Electronic Signatures in Global and National Commerce Act (E-SIGN).
Pursuant to the Federal Motor Carrier Safety Administration regulations concerning electronic signatures, the parties consent and agree to the extent practical to conducting business electronically, including, but not limited to, the use of electronic mail, web-portals, electronic signatures and to the use of other practical electronic methods developed from time-to-time.
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.
The federal Fair Credit Reporting Act (FCRA) promotes the accuracy, fairness, and privacy of information in the files of consumer reporting agencies. There are many types of consumer reporting agencies, including credit bureaus and specialty agencies (such as agencies that sell information about check writing histories, medical records, and rental history records). Here is a summary of your major rights under FCRA. For more information, including information about additional rights, go to www.consumerfinance.gov/learnmore or write to: Consumer Financial Protection Bureau, 1700 G Street N.W., Washington, DC 20552.
You have the right to know what is in your file. You may request and obtain all the information about you in the files of a consumer reporting agency (your “file disclosure”). You will be required to provide proper identification, which may include your Social Security number. In many cases, the disclosure will be free. You are entitled to a free file disclosure if:
In addition, all consumers are entitled to one free disclosure every 12 months upon request from each nationwide credit bureau and from nationwide specialty consumer reporting agencies. See www.consumerfinance.gov/learnmore for additional information.
The following FCRA right applies with respect to nationwide consumer reporting agencies:
CONSUMERS HAVE THE RIGHT TO OBTAIN A SECURITY FREEZE
You have a right to place a “security freeze” on your credit report, which will prohibit a consumer reporting agency from releasing information in your credit report without your express authorization. The security freeze is designed to prevent credit, loans, and services from being approved in your name without your consent. However, you should be aware that using a security freeze to take control over who gets access to the personal and financial information in your credit report may delay, interfere with, or prohibit the timely approval of any subsequent request or application you make regarding a new loan, credit, mortgage, or any other account involving the extension of credit.
As an alternative to a security freeze, you have the right to place an initial or extended fraud alert on your credit file at no cost. An initial fraud alert is a 1-year alert that is placed on a consumer’s credit file. Upon seeing a fraud alert display on a consumer’s credit file, a business is required to take steps to verify the consumer’s identity before extending new credit. If you are a victim of identity theft, you are entitled to an extended fraud alert, which is a fraud alert lasting 7 years.
A security freeze does not apply to a person or entity, or its affiliates, or collection agencies acting on behalf of the person or entity, with which you have an existing account that requests information in your credit report for the purposes of reviewing or collecting the account. Reviewing the account includes activities related to account maintenance, monitoring, credit line increases, and account upgrades and enhancements.
States may enforce the FCRA, and many states have their own consumer reporting laws. In some cases, you may have more rights under state law. For more information, contact your state or local consumer protection agency or your state Attorney General. For information about your federal rights, contact:
1.a. Banks, savings associations, and credit unions with total assets of over $10 billion and their affiliates
b. Such affiliates that are not banks, savings associations, or credit unions also should list, in addition to the CFPB:
a. Consumer Financial Protection Bureau1700 G Street, N.W.Washington, DC 20552
b. Federal Trade CommissionConsumer Response Center600 Pennsylvania Avenue, N.W.Washington, DC 20580(877) 382-4357
2. To the extent not included in item 1 above:a. National banks, federal savings associations, and federal branches and federal agencies of foreign banks
b. State member banks, branches and agencies of foreign banks (other than federal branches, federal agencies, and Insured State Branches of Foreign Banks), commercial lending companies owned or controlled by foreign banks, and organizations operating under section 25 or 25A of the Federal Reserve Act.
c. Nonmember Insured Banks, Insured State Branches of Foreign Banks, and insured state savings associations
d. Federal Credit Unions
a. Office of the Comptroller of the CurrencyCustomer Assistance Group1301 McKinney Street, Suite 3450Houston, TX 77010-9050
b. Federal Reserve Consumer Help CenterP.O. Box 1200Minneapolis, MN 55480
c. FDIC Consumer Response Center1100 Walnut Street, Box #11Kansas City, MO 64106
d. National Credit Union AdministrationOffice of Consumer Financial Protection (OCFP)Division of Consumer Compliance Policy and Outreach1775 Duke StreetAlexandria, VA 22314
3. Air carriers
Asst. General Counsel for Aviation Enforcement & ProceedingsAviation Consumer Protection DivisionDepartment of Transportation1200 New Jersey Avenue, S.E.Washington, DC 20590
4. Creditors Subject to the Surface Transportation Board
Office of Proceedings, Surface Transportation BoardDepartment of Transportation395 E Street, S.W.Washington, DC 20423
5. Creditors Subject to the Packers and Stockyards Act, 1921
Nearest Packers and Stockyards Administration area supervisor
6. Small Business Investment Companies
Associate Deputy Administrator for Capital AccessUnited States Small Business Administration409 Third Street, S.W., Suite 8200Washington, DC 20416
7. Brokers and Dealers
Securities and Exchange Commission100 F Street, N.E.Washington, DC 20549
8. Federal Land Banks, Federal Land Bank Associations, Federal Intermediate Credit Banks, and Production Credit Associations
Farm Credit Administration1501 Farm Credit DriveMcLean, VA 22102-5090
9. Retailers, Finance Companies, and All Other Creditors Not Listed Above
Federal Trade CommissionConsumer Response Center600 Pennsylvania Avenue, N.W.Washington, DC 20580(877) 382-4357
Please check here if you would like to receive (where you have such a right under the applicable state law) a copy of your background report if one is obtained on you by the Company. Yes
Please check here if you would like to receive a copy of the FCRA Summary of Rights Yes
IST Logistics may wish to obtain and use a “consumer report” and/or an “investigative consumer report” from a “consumer reporting agency” when: considering your application for employment/qualification/contract; making a decision whether to offer you employment/a contract; deciding whether to continue your employment/contract (if you are hired/qualified); and making other employment/qualification/contract-related decisions directly affecting you. These terms are defined in the Fair Credit Reporting Act (“FCRA”), a law which applies to you. As an applicant for employment/qualification/contract or an employee/contractor of IST Logistics, you are a “consumer” with rights under the FCRA.
A “consumer reporting agency” is a person or business that, for monetary fees, dues or on a cooperative nonprofit basis, regularly assembles or evaluates consumer credit information or other information on consumers for the purpose of furnishing “consumer reports” to others, such as IST Logistics. A “consumer report” is any written, oral or other communication of any information by a “consumer reporting agency” bearing on a consumer’s credit worthiness, credit standing, credit capacity, character, general reputation, personal characteristics, motor vehicle record, or mode of living that is used or collected for the purpose of serving as a factor in establishing the consumer’s eligibility for employment/qualification/contract purposes. Additionally, IST Logistics may seek information about your employment/contract history and/or educational background.
If IST Logistics obtains a “consumer report” about you, and if it considers any information in the “consumer report” when making an employment/qualification related decision that directly and adversely affects you, you will be provided a copy of the report, the name, address and telephone number of the reporting agency, and a summary of your rights under the Fair Credit Reporting Act. You also may contact the Consumer Response Center about your rights under the FCRA as a “consumer” with regard to “consumer reports” and “consumer reporting agencies.”
I acknowledge that I have carefully read and understand the DISCLOSURE and hereby consent to and authorize IST Logistics and/or its agents to obtain “consumer reports” and/or “investigative consumer reports” from a “consumer reporting agency” at any time after receipt of this Authorization and at any time throughout my employment or contract term, if applicable. I also authorize IST Logistics to consider the “consumer report” when making decisions regarding my employment/qualification at any time before or during that employment/contract.
I understand I have rights under the FCRA, including the rights discussed in the FCRA Summary of Rights which has been provided to me along with this Disclosure/Authorization form. I understand this Authorization shall remain on file and shall serve as an ongoing Authorization for the Company to obtain consumer reports, investigative consumer reports and criminal background reports at any time during my contract or employment and the qualification process with respect thereto. I acknowledge receiving a written Summary of Rights under the FCRA along with this Disclosure and Authorization form. I understand that upon termination of my contract or employment for any reason this Authorization shall be of no further effect.
California, Minnesota, or Oklahoma candidates only: Please check here if you would like to receive (where you have such a right under the applicable state law) a copy of your background report if one is obtained by the Company Yes
In connection with your application for employment with IST Logistics (“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 Carrier Safety Administration (FMCSA).
When the application for employment is submitted in person, 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 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 submitted 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 of taking adverse action oral, written or electronic notification that adverse action has been taken based in whole or in part on information obtained 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 reasons why the adverse action was taken; and that you may, upon providing proper identification, request a free copy of the report and may dispute with the FMCSA the accuracy or completeness of any 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 of 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 capability 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.
If you agree that the Prospective Employer may obtain such background reports, please read the following and sign below:
I authorize IST Logistics (“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 https://dataqs.fmcsa.dot.gov. If I challenge crash or inspection information reported by a 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 also appear, and remain, on my PSP report.
I have read the above Disclosure Regarding Background Reports provided to me by Prospective Employer and I understand that if I sign this Disclosure and Authorization, Prospective Employer may obtain a report 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.
Notice: The prospective employment concept referenced in this form contemplates the definition of “employee” contained at 49 CFR 383.5
You understand that information you provide regarding current/previous employers may be used and that these employers will be contacted, for the purpose of investigating your safety performance history information as required by 49 CFR 391.23 (d) and (e). Under 49 CFR 391.23, you have the following due process rights regarding the investigative information that will be provided to IST Logistics:
If you have previous Department of Transportation regulated employment history in the preceding three years and wish to review previous employer-provided investigative information, you must submit a written request to IST Logistics, which may be done at any time, including when applying, or as late as thirty days after being employed/qualified or being notified of denial of employment/qualification. IST Logistics must provide this information to you within five business days of receiving the written request. If IST Logistics has not yet received the requested information from the previous employer(s), then the five business days deadline will begin when IST Logistics receives the requested safety performance history information. If you do not arrange to pick up or receive the requested records within thirty days of IST Logistics making them available, IST Logistics may consider you to have waived your request to review the records.
I Accept *Yes
7020 Cline Avenue
Hammond, IN 46323
I authorize per 49 CFR Part 40 the release of information to IST Logistics from my DOT regulated drug and alcohol testing records by the carriers (companies/schools) listed below, for the sole purpose of transmitting such records to IST Logistics. I authorize release of the following information concerning DOT drug and alcohol testing violations, including pre-employment tests during the past three years:
The information that I have authorized IST Logistics to review involves tests required by DOT. If any carrier (companies/schools) listed below furnishes IST Logistics with information concerning items (i) through (v) above, I also authorize that carrier (companies/schools) to release and furnish the dates of my alcohol tests with results of 0.02 or greater but less than 0.04 during the three-year period.
I have read and fully understand this Authorization to Obtain Past Drug and Alcohol Test Results. In signing this form, I certify that all of the information which I have furnished on this form is true and complete and that I have identified all of the companies for which I have worked or applied for work as a driver during the past three years.