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Cushing Transportation, Inc.

Owner-Operators Application

Complete all fields and hit the 'submit' button at the end.

You will receive a confirmation number to indicate your application was received.

Personal Information

First Name *

Last Name *

Social Security # *

Birthdate *

Address 1 *

Address 2

City *

State *

Postal Code *

Email Address

Phone # *

Cell Phone #

Are you legally authorized to work in the United States? *

Yes

Have you ever been convicted of a felony? *

Yes

If yes, please explain.

Availability

Shift preferred *

Days

Nights

No Preference

Employment History

All drivers must provide the following information on all employers during the preceding three years. List complete address and phone number for each employer. If applying for a position driving a commercial motor vehicle*, you must also provide an additional seven years of employment information for those employers for whom the applicant operated such vehicle (a total of 10 years). Your present and previous employers will be contacted for the purpose of investigating your safety performance history as required by 391.23 of the FMCSRs.

Employer

Address

Phone

From (MM/YY)

To (MM/YYYY)

Salary

Position

Contact

Reason for Leaving

Employer

Address

Phone

From (MM/YYYY)

To (MM/YYYY)

Salary

Position

Contact

Reason for Leaving

Employer

Address

Phone

From (MM/YYYY)

To (MM/YYYY)

Salary

Position

Contact

Reason for Leaving

References

Name

Relationship

City/State

Phone

Email Address

Name

Relationship

City/State

Phone

Email Address

Name

Relationship

City/State

Phone

Email Address

Experience and Qualifications - Driver

Drivers License *

State *

Type *

Expiration Date *

	Yes	No
Have you ever been denied a license, permit or privilege to operate a motor vehicle?	Yes	No
Has any license, permit or privilege ever been suspended or revoked?	Yes	No
Have you ever tested positive for, or refused to take, a pre-employment or random Drug and/or Alcohol test in the past Three (3) years?	Yes	No

For any YES answers to the above questions, please provide details:

To be read and signed by applicant

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

I authorize you to make such investigations and inquiries of my personal, employment, financial and other related matters as may be necessary in arriving at an employment decision. I understand that consumer reports may be requested from HireRight. These reports may Inc.lude: previous employer verifications, reason for termination, accidents, driving records, workers compensation claims, etc. I further understand that such reports may contain information from federal, state or other agencies. I hereby release employers, schools, healthcare providers and other persons from all liability in responding to inquiries and releasing information in connection with my application. I further authorize The Cushing Transportation, Inc. to release any and all information regarding myself to any of its lessees that Cushing Transportation, Inc. may consider assigning me to. You have the right to review information provided to us by your previous employers and have any errors in such information corrected by your previous employer as stated in section 391.23 (i) of the FMCSRs. Should you wish to review this information you must submit a written request to us, your prospective employer, as stated in section 391.23 (i) of the FMCSRs.

I authorize, per 49 CFR Part 40 of FMCSRs, the release of information from my DOT regulated drug and alcohol testing records by my previous employers to HireRight for the sole purpose of transmitting such records to The Cushing Transportation, Inc.and its representatives/agents/clients. I authorize the release of the following information concerning DOT drug and alcohol testing violations Inc.luding pre-employment tests during the past three years: (i) alcohol tests with a result of 0.04 or higher; (ii) verified positive drug tests; (iii) refusals to be tested ( Inc.luding verified adulterated or substituted results); (iv) other violations of DOT drug and alcohol testing regulations; (v) information obtained from previous employers of drug and alcohol rule violation(s); and (vi) documents, if any, of completion of return-to-duty process following a rule violation. I hereby authorize my worksite employer to submit copies of my current and future drug test results to the Cushing Transportation, Inc. This authorization shall expire if and when my worksite employer is no longer a client of the Cushing Transportation, Inc. The information I have authorized HireRight to review involves tests required by the DOT. If any carrier/company/school for whom I was previously employed furnishes HireRight with information concerning items (i) through (vi) above, I also authorize that carrier/company/school to release and furnish the dates of my negative drug and/or alcohol tests with results below 0.04 during the three year period and the name and phone number of any substance abuse professionals who evaluated me during the past three years.

The Cushing Transportation, Inc. participates in E-Verify, which means if you are hired information from your I-9 form will be provided to the Social Security Administration, and if necessary, the Department of Homeland Security, to confirm work authorization. In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the Company.

By checking this box, I consent to my physical signature and certify that the information is true and correct.

IMPORTANT DISCLOSURE

REGARDING BACKGROUND REPORTS FROM THE PSP Online Service

In connection with your application for employment with CUSHING TRANSPORTATION, INC. (“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 F air 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 ty 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 PS P 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 reports, please read the following and Check below:

I authorize CUSHING TRANSPORTATION, INC. (“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: 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 form to obtain an Applicant’s consent. The language must be used in whole, exactly as provided. 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.

LAST UPDATED 12/22/2015

By checking this box, I consent to my physical signature and certify that the information is true and correct.