Release Authorization To Previous Employer Company
Work Record and Consumer Reports Release Authorization: Per 49 CFR §391, I hereby authorize without
liability, any person or organization, including but not limited to any educational institution, training facility
or any institution whose name I may have given as reference, or by whom I have been previously employed
to furnish Complete Energy Services – Well Services Division, Inc., hereafter “The Company”, any
information they may have concerning my character, habits, ability, financial responsibility, job
performance and reasons for leaving employment. Furthermore, there may be entities that The Company
does business with that may request investigative reports or consumer reports which apply to my
background. In this case, these reports would apply to my assignment to projects related to the customer,
permission to be on the customer’s premises and to handle products and/or other security concerns of the
customer. I hereby release all such persons and organizations from any claims of damages of any kind,
which may occur to me by reasons of furnishing such information. I hereby authorize any law enforcement
agency or court of record to furnish The Company with information concerning motor vehicle records or
any felony or misdemeanor of which I have been convicted.
Medical Records Release Authorization: I authorize The Company to obtain medical documentation or
information concerning my past or present medical status. I release anyone with such records from liability,
claim or damages for providing my medical information to The Company.
Drug and Alcohol History Release Authorization: Per 49 CFR §40 and §382, I authorize and require my
previous and/or current employer(s) as well as any other person or company listed by me in writing, by
verbal interview, by whom I was employed or to whom I applied for employment to release to The
Company the date, type of test and result of all drug and alcohol tests taken by me, including the date and
type of test for any refusals by me to take a drug and/or alcohol test. I also authorize the release of all
information concerning my referral to a Substance Abuse Professional (SAP), including records pertaining to
my evaluation and treatment (if required by a SAP). I understand that this information is limited to the
following DOT‐regulated testing items:
1. Alcohol tests with a result of 0.04 or higher;
2. Verified positive drug tests;
3. Refusals to be tested;
4. Other violations of DOT agency drug and alcohol testing regulations;
5. Information obtained from previous employers of a drug and alcohol rule violation;
6. Documentation, if any, of completion of the return‐to‐duty process following a rule violation.
I authorize the release by whatever means is most expedient that will maintain the confidentiality of the
information transmitted. I agree to hold harmless any past employer, person or company I applied with as
well as their employees, agents or representatives from all liability or damage that may arise from the
release of the information specifically authorized here.
RELEASE AUTHORIZATION AND ACKNOWLEDGEMENT OF MANDATORY NOTIFICATIONS, DISCLAIMERS, AND
AGREEMENTS
SIGNATURE DATEPRINTED NAME SOCIAL SECURITY NUMBER
Collection of the individual’s Social Security Number (SSN) is required in order to positively identify the individual. We will forward this release to all previous employers to obtain your United States Department of Transportation safety performance
COMPLETE ALL BLOCKS – PLEASE PRINT
NAME:
LAST FIRST MIDDLE INITIAL
Current ADDRESS: City, State, Zip Code: HOME PHONE: CELL PHONE: ADDRESSES FOR THE PAST THREE (3) YEARS
ADDRESS CITY STATE ZIP HOW LONG
Present: Previous: Previous:
*** REQUIRED INFORMATION ***
DOT‐REGULATED EXPERIENCE (CHECK BOX IF NONE )CLASS TYPE DATES STATES OPERATED
IN
FROM TO
Straight Truck Box Van Flatbed Dump
Straight Truck ‐ Cargo Tank HM Non‐HM
Straight Truck + Trailer/Semi‐Trailer Box Van Flatbed Dump Truck‐Tractor + Trailer/Semi‐Trailer Box Van Flatbed Dump
Truck‐Tractor + Cargo Tank HM Non‐HM
Other (specify)
CURRENT DRIVER LICENSE DATA
NUMBER TYPE/CLASS ENDORSEMENTS RESTRICTIONS STATE EXPIRES
Have you ever had your current driver’s license, permit or privilege suspended, revoked or denied? YES NO
If YES, explain:
PREVIOUS DRIVER LICENSE DATA ‐ INDICATE ANY DRIVER LICENSE PREVIOUSLY HELD
NUMBER TYPE
/CLASS ENDORSEMENTS RESTRICTIONS STATE
SUSPENDED, REVOKED, OR DENIED? (Y/N) DATES SUSPENDED, REVOKED, OR DENIED REASON (REQUIRED)
ACCIDENT RECORD FOR THE PAST THREE (3) YEARS (CHECK BOX IF NONE )
DATE NATURE OF ACCIDENT (HEAD‐ON, REAR‐END, UPSET, ETC.) FATALITIES INJURIES
TRAFFIC CONVICTIONS AND FOREFITURES FOR THE PAST THREE (3) YEARS‐OTHER THAN PARKING VIOLATIONS FOR WHICH I HAVE BEEN CONVICTED OR FORFEITED BOND OR COLLATERAL (CHECK BOX IF NONE )
DATE LOCATION CHARGE PENALTY
FULL 10 YEAR WORK HISTORY REQUIRED ‐ LIST THE MOST RECENT FIRST
JOB TITLES & DATES REQUIRED
EMPLOYER DATE
FROM TO
NAME: MO. YR. MO. YR.
ADDRESS: POSITION:
STREET CITY STATE/ZIP
PAY:
CONTACT: PHONE: REASON FOR LEAVING:
Were you subject to the Federal Motor Carrier Safety Regulations while employed by this previous employer? Was the job was designated as a “safety sensitive function” in any DOT‐regulated mode subject to alcohol and drug testing requirements as required by 49 CFR Part 40? YES YES NO NO EMPLOYER DATE FROM TO
NAME: MO. YR. MO. YR.
ADDRESS: POSITION:
STREET CITY STATE/ZIP
PAY:
CONTACT: PHONE: REASON FOR LEAVING:
Were you subject to the Federal Motor Carrier Safety Regulations while employed by this previous employer? Was the job was designated as a “safety sensitive function” in any DOT‐regulated mode subject to alcohol and drug testing requirements as required by 49 CFR Part 40? YES YES NO NO EMPLOYER DATE FROM TO
NAME: MO. YR. MO. YR.
ADDRESS: POSITION:
STREET CITY STATE/ZIP
PAY:
CONTACT: PHONE: REASON FOR LEAVING:
Were you subject to the Federal Motor Carrier Safety Regulations while employed by this previous employer? Was the job was designated as a “safety sensitive function” in any DOT‐regulated mode subject to alcohol and drug testing requirements as required by 49 CFR Part 40? YES YES NO NO EMPLOYER DATE FROM TO
NAME: MO. YR. MO. YR.
ADDRESS: POSITION:
STREET CITY STATE/ZIP
PAY:
CONTACT: PHONE: REASON FOR LEAVING:
Were you subject to the Federal Motor Carrier Safety Regulations while employed by this previous employer? Was the job was designated as a “safety sensitive function” in any DOT‐regulated mode subject to alcohol and drug testing requirements as required by 49 CFR Part 40? YES YES NO NO EMPLOYER DATE FROM TO
NAME: MO. YR. MO. YR.
ADDRESS: POSITION:
STREET CITY STATE/ZIP
PAY:
CONTACT: PHONE: REASON FOR LEAVING:
Were you subject to the Federal Motor Carrier Safety Regulations while employed by this previous employer? Was the job was designated as a “safety sensitive function” in any DOT‐regulated mode subject to alcohol and drug testing requirements as required by 49 CFR Part 40? YES YES NO NO EMPLOYER DATE FROM TO
NAME: MO. YR. MO. YR.
ADDRESS: POSITION:
STREET CITY STATE/ZIP
PAY:
CONTACT: PHONE: REASON FOR LEAVING:
Do you have a legal right to work in the United States? YES NO
Have you ever been convicted of a traffic felony in a CMV? YES NO
If YES, explain on a separate sheet of paper. This information will remain confidential. Conviction of a crime is not an automatic bar to employment. All circumstances will be considered.
Do you have a current medical examiner’s certificate? YES NO Expiration Date:
If you have any interstate or intrastate medical, vision, or limb waivers, check the appropriate box and type below
Interstate Expiration Date: Intrastate State: Expiration Date:
Type: Insulin Limb Vision Other (Specify)
Are you currently subject to an out‐of‐service order? YES NO
Are you currently disqualified to drive? YES NO
Describe any trucking, transportation, training, courses, specialized equipment or other experience that may be helpful:
DOT‐AGENCY DRUG AND ALCOHOL TESTING
Have you ever tested positive, or refused to test, on any pre‐employment drug or alcohol test administered by an employer to which you applied for, but did not obtain, safety‐sensitive transportation work covered by DOT agency drug and alcohol testing rules? YES NO Have you ever tested positive, or refused to test, on any random, post‐accident or reasonable suspicion drug and/or alcohol test while engaged in safety‐sensitive transportation work covered by USDOT agency drug and alcohol testing rules? YES NO If you answered YES to either of the two questions above, you must provide copies of all Substance Abuse Professional referral, evaluation, and treatment documentation including return‐to‐duty and follow‐up testing chain of custody forms and results.
OTHER COMPENSATED WORK
Are you currently working for another employer? YES NO
At this time do you intend to work for another employer while employed with this company? YES NO
GENERAL INFORMATION
Are you under the age of 18? YES NO If under age 18, can you supply working papers? YES NO N/A
NOTIFICATION AND AGREEMENT
PLEASE READ BEFORE SIGNING I CERTIFY THAT ALL ANSWERS GIVEN BY ME ARE TRUE, ACCURATE AND COMPLETE, I UNDERSTAND THAT THE FALSIFICATION, MISREPRESENTATION OR OMISSION OF FACT ON THIS APPLICATION (OR ANY OTHER ACCOMPANYING OR REQUIRED DOCUMENTS) WILL BE CAUSE FOR DENIAL OF EMPLOYMENT OR IMMEDIATE TERMINATION OF EMPLOYMENT, REGARDLESS OF WHEN OR H0W DISCOVERED. Questions regarding this statement should be directed to any employment interviewer before signing. The application will be given every consideration, but its receipt does not imply that the applicant will be employed. It is the policy of the company to afford equal opportunity to all employees and applicants for employment without regard to age, race, religion, color, sex, national origin, marital status or pregnancy, and to afford equal opportunities to disabled veterans, veterans of the Vietnam era, and individuals with a disability, any and other characteristic protected by Federal, State or Local law. I authorize the investigation of all statements and information contained in this application. I release from all liability anyone supplying such information and I also release the employer from all liability that might result from making an investigation. I hereby certify that all of the facts and information listed on this employment application are true and complete. I understand that any false, incomplete or misleading information given by me on this application is sufficient cause for rejection of this application. I also understand and agree that any such false, incomplete, or misleading information discovered on this application at any time after I am employed may result in dismissal. If I am offered employment, I understand that such an offer will be conditioned upon satisfactory results of a background investigation and/or Company medical examination or inquiry, including a drug‐screening test. I consent to the investigation, physical and drug test.I hereby authorize the Company to investigate all statements contained in this application, to interview the references and previous employers listed in the application, and to obtain a report from a consumer‐reporting agency to be used for employment purposes in accordance with the Fair Credit Reporting Act. I authorize the references and previous employers listed to give the Company all facts, opinions and evaluations concerning my previous employment and any other information they may have, personal or otherwise, and release all such information to the Company, including, but not limited to, any liability or invasion of privacy. I understand that I will be provided a separate consent form authorizing a consumer report and/or investigative consumer report. If I am applying for a position as a Driver within any division of Complete Production Services, I understand that information I provide regarding current and/or previous employers may be used, and those employer’s) contacted, for the purpose of investigating my safety performance history as required by 49 CFR 391.23(d) and (e). I understand that I have the right to: Review information provided by previous employers; Have errors in the information corrected by previous employers and for those previous employers to re‐send the corrected information to the prospective employer; and
Have a rebuttal statement attached to the alleged erroneous information, if the previous employer(s) and I cannot agree on the accuracy of the information.
In consideration of my employment, I agree to conform to the company’s rules and regulations, and I agree that my employment and compensation can be terminated, with or without cause, and with or without notice, at any time, at either my or the company’s option. I also understand and agree that the terms and conditions of my employment may be changed, with or without cause, and with or without notice, at any time by the company.
I further understand and voluntarily agree as a condition of employment or my continued employment, that I may be requested by the Company to submit to a urinalysis or other drug screen test and that my failure to take such test(s) when requested to do so or unsatisfactory test results will disqualify me from consideration for employment, or if I am then employed, may result in immediate dismissal.
I acknowledge that I have read and understand the above statements and hereby grant permission to confirm the information supplied on this application by me.
MANDATORYUSEFORALLACCOUNTHOLDERS
IMPORTANT NOTICE
REGARDING BACKGROUND REPORTS FROM THE PSP Online Service
I. In connection with your application for employment with Complete Energy Services ("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.
The Prospective Employer cannot obtain background reports from FMCSA unless you consent in writing.
If you agree that the Prospective Employer may obtain such background reports, please read the following and sign below:
2. I authorize Complete Energy Services("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 consenting to 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.
3. 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 am challenging 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.
4. Please note: 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 FMCSR violations that have been adjudicated by a court of law will also appear, and remain, on a PSP report.
I have read the above Notice Regarding Background Reports provided to me by Prospective Employer and I understand that if I sign this consent form, 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.
________________________
______________________________
Date
Signature
______________________________
Print Name
NOTICE: This form is made available to monthly account holders by NlCT 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 provided in paragraphs 1-4 of this document to obtain a prospective Applicant's consent. The language must be used in whole, exactly as provided. The language may be included with other consent forms or language at the discretion of the account holder, provided the four paragraphs remain intact and the language is unchanged.
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Texas CES, Inc,
