Independent Contractor Background Report
NAME
TO BE READ AND SIGNED BY CONTRACTOR
I hereby authorize Professional Automotive Relocation Services, Inc. (PARS), Indaco Risk
Advisors, Allied Insurance, any individual, current or former employer, educational institution,
or military branch listed in my report to disclose information in good faith to its representatives,
orally or in writing, for use in rating and/or underwriting insurance for which the above named
company may apply, and any renewal thereof. Furthermore, pursuant to Sections 382.413,
391.23, and 391.25 of the Federal Motor Carrier Safety Regulations, I authorize the
aforementioned parties to disclose any information necessary to assess my fitness as an
independent contractor, including, but not limited to, job performance, reasons for termination,
salary, job duties, eligibility to rehire, work habits, disciplinary actions, training, education,
experience, knowledge, skills, qualifications, professional conduct, evaluation information, and
attitude. I release these individuals and entities, and their representatives, from all liability for
providing such disclosures and for any consequences that may occur as a result of those
disclosures. I also understand that I am also responsible for reporting all subsequent motor
vehicle violations to PARS within 24 hours of any violation.
I understand that I am required to abide by all rules and regulations of the Independent
Contractor Agreement (ICA). I understand that false or misleading information given in my
background report or interviews may result in termination of the Independent Contractor
Agreement.
I understand that information I provide regarding current and/or previous employers and/or jobs,
previous drug and alcohol test results, and my driving record may be used, and those employer(s)
will be contacted, for the purpose of investigating may safety performance history as required by
49CFR 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 corrected information to the PARS.
•
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.
SIGNATURE
DATE
Page 1 of 4
Rev. 11/2012
INDEPENDENT CONTRACTOR TO COMPLETE
(Answer all questions – Please print)
Name
Email
Social Security No.
Phone No.
List your addresses of residency for the past three years:
Current Address:
Street
State
Previous Addresses:
City
How Long?
Zip
Street
City
State
Zip
Street
City
State
Zip
Street
City
State
Zip
Yr./Mo.
How Long?
How Long?
How Long?
Yr./Mo
Yr./Mo
Yr./Mo
Do you have the legal right to work in the United States? Yes ☐ No ☐
Date of Birth
Can you provide proof of age? Yes ☐ No ☐ (required for Commercial Drivers)
Are you now currently employed? Yes ☐ No ☐
If not, how long since leaving last employment?
Where you referred? Yes ☐ No ☐
If yes, by whom
Have you ever been convicted of a felony? Yes ☐ No ☐
If yes, please explain fully, If more room is needed, use separate sheet of paper
Conviction of a crime is not an automatic elimination – all circumstances will be considered.
Is there any reason you might be unable to perform the task of the job for which you are applying? Yes☐ no ☐
If yes, please explain
PARS is a tobacco free company. No person is permitted to use tobacco in any way at any time. Is there any
reason you would not be able to adhere to this? Yes ☐ No ☐
If yes, please explain
Overnight Independent Contractor? Yes ☐ No ☐
If Yes, Maximum Number of Days:
Page 2 of 4
Rev. 11/2012
EMPLOYMENT/JOB DESCRIPTION HISTORY
All independent contractors to drive interstate commerce must provide the following information on all employees during the preceding three (3) years: complete
mailing address, street number, city, state, and zip code.
Independent contractors to driver a commercial motor vehicle* in interstate or interstate commerce shall also provide an additional seven (7) years’ information on
those employers for whom the application operated such vehicle. (Please note: List employees in reverse order, starting with most recent. If more room is needed,
use separate sheet of paper)
Employer/Job Description
Contact
Date (Yr./Mo.)
To
Name
Position Held
Address
Reason for Leaving
City
State
Zip
Were you subject to the FMCSRs† while you were employed? Yes ☐ No ☐
Was your job designed as a safety- sensitive function in any DOT –regulated mode subject to the drug and alcohol
testing requirements? Yes ☐ No ☐
From
Employer/Job Description
Contact
Date (Yr./Mo.)
To
Name
Position Held
Address
Reason for Leaving
City
State
Zip
Were you subject to the FMCSRs† while you were employed? Yes ☐ No ☐
Was your job designed as a safety- sensitive function in any DOT –regulated mode subject to the drug and alcohol
testing requirements? Yes ☐ No ☐
From
Employer/Job Description
Date (Yr./Mo.)
From
To
Name
Contact
Position Held
Address
Reason for Leaving
City
State
Zip
Were you subject to the FMCSRs† while you were employed? Yes ☐ No ☐
Was your job designed as a safety- sensitive function in any DOT –regulated mode subject to the drug and alcohol
testing requirements? Yes ☐ No ☐
Employer/Job Description
Date (Yr./Mo.)
From
To
Name
Contact
Position Held
Address
Reason for Leaving
City
State
Zip
Were you subject to the FMCSRs† while you were employed? Yes ☐ No ☐
Was your job designed as a safety- sensitive function in any DOT –regulated mode subject to the drug and alcohol
testing requirements? Yes ☐ No ☐
*Includes vehicles having a GVW R 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
†The Federal Motor Carrier Safety Regulations (FMCSRs) apply to anyone operating a motor vehicle on a highway in interstate commerce to transport
passengers or property when the vehicle: (1) weighs or has a GVWR of 1 0,001 pounds or more, (2) is designed or used to transport 9 or more passengers, OR
(3) is of any size and is used to transport hazardous materials in a quantity requiring placarding
Accident Record: Please list all for the past three (3) years or more (If more room is needed, use separate sheet of
paper)
Date
Nature of Accident
Fatalities
Injuries
Hazardous Material spill
Last Accident
Next Previous
Next Previous
Page 3 of 4
Rev. 11/2012
Traffic Convictions and Forfeitures: Please list all for the past three (3) years or more (If more room is needed, use
separate sheet of paper)
Location
Date
Charge
Penalty
EXPERIENCE AND QUALIFICATIONS
Driver Licenses: Please list all driver licenses or permits held in the past 3 years
State
License No.
Type
Driver
Licenses
Years Held
A. Have you ever been denied a license, permit or privilege to operate a motor vehicle? Yes ☐
If Yes, please explain
B. Has any license, permit or privilege ever been suspended or revoked? Yes ☐ No ☐
If Yes, please explain
Expires
No ☐
Driving Experience: (please check Yes or No)
Class of Equipment
Dates
Type of Equipment
Straight Truck
Tractor and Semi-Trailer
Tractor – Two trailers
Tractor – Three Trailers
Motor coach – School Bus (more than 8 passengers)
Motor coach – School Bus (more than 15 passengers)
Other
From
Approx. No. of Miles
To
(TOTAL)
(VAN, TANK, FLAT, DUMP, REFER)
Van
(VAN, TANK, FLAT, DUMP, REFER)
Van
(VAN, TANK, FLAT, DUMP, REFER)
Van
(VAN, TANK, FLAT, DUMP, REFER)
Van
Please list states operated in for the last five years:
List special courses or training that will help you as a driver:
Which safe driving awards do you hold and from whom:
Experience and qualifications – Other:
Please list and trucking, transporting or other experience that may help in your work for this company:
List courses and training other than shown elsewhere in this application:
List special equipment or technical materials you can work with (other than those already listed)
Education:
Choose the highest grade completed:
College:
School Name
High School
School Name
Grade School 18 2 3 4 5 6 7 8
High School 0
1234
College 0
1234
City/state
Dates attended
City/state
Dates attended
THIS CERTIFIES THAT THIS FORM WAS COMPLETED BY ME, AND THAT ALL ENTRIES ON IT AND INFORMATION IN IT ARE TRUE AND
COMPLETE TO THE BEST OF MY KNOWLEDGE:
SIGNATURE
DATE
Page 4 of 4
Rev. 11/2012