Make a Payment - Norfleet Transportation

APPLICATION

Step 1 of 7

Fill out the following form and call us at (800) 454-4891 or email us for any questions that you may have. In compliance with Federal and State equal employment opportunity laws, qualified applicants are considered for all positions without regard to race, color, religion, sex, national origin, age, marital status, veteran status, non-job related disability, or any other group status. By filling out and submitting this form, you authorize Norfleet Transporation to make such investigations and inquiries of my personal, employment, financial or medical history and other related matters as may be necessary in arriving at an employment decision. (Generally, inquiries regarding medical history will be made only if and after a conditional offer of employment has been extended.) I hereby release employers, schools, health care providers and other persons from all liability in responding to inquiries and releasing information in connection with my application. 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. I understand that information I provide regarding current and/or previous employers may be used, and those employer(s) will be 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.

Company Name

Region/District/Branch

Company Address

(Use Additional Employment History Information form if necessary All applicants wishing to drive in interstate commerce must provide the following information on all employers during the preceding three years. You must give the same information for all employers for whom you have driven a commercial vehicle seven years prior to the initial three years (total of ten year employment record). You are required to list the complete mailing address: street number and name, city, state and zip code.

Employment History

Current or Last Employer

Phone Number

Employer Street Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

How Long Did You Work Here?

Reason For Leaving

Were you subject to the FMCSRs** while employed:

Yes

Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40:

Yes

Account For Period Between Jobs

This form is made available with the understanding that J. J. Keller & Associates, Inc. is not engaged in rendering legal, accounting, or other professional services. J. J. Keller & Associates, Inc. assumes no responsibility for the use of this form, or any decision made by an employer which may violate local, state, or federal law.

Recipient employer: The individual identified in SECTION 1 below has indicated that you employ(ed) or use(d) him/her within the last 3 years in a position that involved the operation of a commercial motor vehicle and/or that was subject to U.S. Department of Transportation (DOT)-regulated drug and alcohol testing. In accordance with 49 CFR §§40.25 and 391.23, we are hereby requesting that you supply us with the Safety Performance History of this individual.

Please complete SECTIONS 2 through 4 (as applicable) and return to the prospective employer shown in SECTION 1. APPLICANT: Complete SECTION 1 and submit to prospective employer PROSPECTIVE EMPLOYER: Complete SECTION 5b and send form to current/previous employer. Upon receipt of completed form, complete Section 5b and retain.

TO BE COMPLETED BY PROSPECTIVE EMPLOYEE

Name

First Last

Social Security #

Date of Birth

Previous Employer

Telephone

Fax

Address

City State / Province / Region

to release and forward the information requested by section 4 of this document concerning my Alcohol and Controlled Substance Testing records within the previous 3 years from

Date of Employment Application

To: Norfleet Transportation LLC Address: 25008 Smyth Drive #121Valencia CA 91355 Attention: Administration Phone: (800) 454-4891 In compliance with §40.25(g) and 391.23(h), release of this information must be made in a written form that ensures confidentiality, such as fax, email, or letter. Fax: 678-379-2735 email: info@norfleettransportation.com

Applicant's Signature

Date

I acknowledge receipt of the separate document entitled DISCLOSURE REGARDING BACKGROUND INVESTIGATION, DISCLOSURE REGARDING INVESTIGATIVE BACKGROUND INVESTIGATION and A SUMMARY OF YOUR RIGHTS UNDER THE FAIR CREDIT REPORTING ACT and additional state/city-specific notices and Summary of Rights and certify that I have read and understand those documents. I hereby authorize the evaluation of my driver file by J. J. Keller & Associates, Inc. for compliance with state and federal laws and the acquisition of “consumer reports” (i.e., driving records, criminal history, social security verification, and/or education history) and/or “investigative consumer reports” (i.e., employment and/or education verification) by the Employer (as listed below) at any time after receipt of this authorization and throughout my employment, if applicable. In addition, I hereby authorize any law enforcement agency, administrator, state or federal agency, institution, school or university (public or private), information service bureau, current and past employer, or insurance company to furnish any and all background information requested by J. J. Keller & Associates, Inc., PO Box 368, Neenah, WI 54957-0368, (877)-564-2333, www.jjkeller.com, and/or Employer itself. I agree that a facsimile (“fax”), electronic or photographic copy of this Authorization shall be as valid as the original.

New York applicants only: Upon request, you will be informed whether or not a consumer report was requested by the Company, and if such report was requested, informed of the name and address of the consumer reporting agency that furnished the report. You have the right to inspect and receive a copy of any investigative consumer report requested by the Company by contacting the consumer reporting agency identified above directly or by checking this box. By signing below, you acknowledge receipt of Article 23-A of the New York Correction Law.

New York City applicants only: By signing this form, you further authorize the Company to provide you with a copy of your consumer report, the New York City Fair Chance Act Notice form, and any other documents, to the extent required by law, at the mailing address and/or email address you provide to the Company.

Washington State applicants only: You also have the right to request from the consumer reporting agency a written summary of your rights and remedies under the Washington Fair Credit Reporting Act.

Minnesota and Oklahoma applicants only: Please check this box if you would like to receive a copy of a consumer report if one is obtained by the Company.

California applicants only: Please check this box if you would like to receive a copy of an investigative consumer report at no charge if one is obtained by the Company whenever you have a right to receive such a copy under California law as stated in the Notice Regarding Background Checks per California Law you received.

Note to Residents of New Hampshire, Pennsylvania, Washington, Puerto Rico, and Canadian Provinces — British Columbia, Manitoba, New Brunswick, Newfoundland & Labrador, Northwest Territories, Nunavut, Prince Edward Islands, Quebec, Saskatchewan, and Yukon: State specific or Canadian general motor vehicle release forms must be completed and signed prior to obtaining the reports.

Signature

Date

Company Name

APPLICATION

Company Address

Employment History

Experience and Qualification

Driving Experience

Class of Equipment

Accident History (3 Years)

Traffic Convictions and Forfeitures (3 years)

License Information

TO BE COMPLETED BY PROSPECTIVE EMPLOYEE

BACKGROUND INFORMATION

LATEST NEWS

Truck Transportation Employment Remains Stable, Warehouse Jobs Continue to Decline

Trucking Industry Faces Prolonged Downturn | Insights from Leading Providers

Navigating the Freight Cycle Bottom | November’s Declines and Signs of Stabilization

Quick Links

Our Networks

Contact Us

Thank You!