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License Class

State Issued


Employment History #1


Employment History #2


Employment History #3


Criminal Record

Have you ever been convicted of a felony?
YesNo

Have you ever been convicted, or are any charges pending, for driving while under the influence of alcohol, a narcotic drug, amphetamines or derivatives thereof?
YesNo

Have you ever been denied a license, permit or privilege to operate a motor vehicle?
YesNo

Has any license, permit or privilege ever been suspended or revoked?
YesNo

Have you ever been convicted, or are any charges pending, for reckless or careless operation of a motor vehicle?
YesNo

Have you ever been convicted, or are any charges pending, for possession, sale or use of a narcotic drug, amphetamines, or derivatives thereof?
YesNo

Have you ever been refused any type of insurance or been denied bonding?
YesNo

Have you ever been discharged or suspended?
YesNo

Do You have any Pending Misdemeanor or Felony Charges?
YesNo

Have you ever refused 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?
YesNo

IF you answered YES to any of the questions above, please explain the details and when they occurred.

Additional Comments


Final Section

Fair Credit Reporting Act Disclosure Statement
The applicant, in connection with this service, authorize all corporations, companies, credit agencies, educational institutions, law enforcement agencies, military services, former employers and individuals to release information they may have about me to Raider Express and their agents, and release them from any liability or responsibility for doing so. I further authorize the procurement of an investigative consumer report and understand that such a report may contain information about my background, character and personal reputation and that further information may be available upon written request within a reasonable period of time.
YesNo

Employer Verification Disclosure Statement
By applying my electronic signature, I the applicant, hereby authorize the companies listed in my information sheet all records of employment, including assessments of my job performance, ability and fitness level, accident history, as well as alcohol & drug testing information to Raider Express. I hereby release this company from any and all liability of any type as a result of providing the information requested to Raider Express.
YesNo

I understand this notice will also apply to any future update reports that may be requested
By applying my electronic signature, I the applicant, hereby authorize the companies listed in my information sheet all records of employment, including assessments of my job performance, ability and fitness level, accident history, as well as alcohol & drug testing information to Raider Express. I hereby release this company from any and all liability of any type as a result of providing the information requested to Raider Express.

By Clicking Yes, you are electronically signing all disclosure agreements and are in full agreement with the terms.You affirmatively consent to the use of this electronic form ("e-form") and acknowledge your right, or option, to complete this Contractor/Driver Information Sheet in a non-electronic form. Your consent to use this electronic Contractor/Driver Information Sheet may be subsequently withdrawn through written notice to Raider Express. Your execution of this Contractor/Driver Information Sheet, by electronic signature, affirms the foregoing information is true and correct to the best of your knowledge.
YesNo

Affirmative Consent
You affirmatively consent to the use of this electronic form ("e-form") and acknowledge your right, or option, to complete this Contractor/Driver Information Sheet in a non-electronic form. Your consent to use this electronic Contractor/Driver Information Sheet may be subsequently withdrawn through written notice to Raider Express. Your execution of this Contractor/Driver Information Sheet, by electronic signature, affirms the foregoing information is true and correct to the best of your knowledge.By checking the following box and typing your name, you are electronically signing all disclosure agreements and are in full agreement with the terms & PSP Consent Form.
YesNo

Click Here to View the PSP Consent Form Regarding Background Reports from the PSP Online Serivce