I certify that I personally completed this application and
that all of the information is true and correct. I
hereby request and authorize Midwest Specialized
Transportation, Inc. to cause to be conducted, at any
time, an investigation of my background for employment
purposes, which may include, but is not limited to, any
information relating to my character, general
reputation, personal characteristics, criminal history,
past work experience, educational background, alcohol or
drug test results, or failure to submit to an alcohol or
drug test, or any other information about me which may
reflect upon my potential for employment gathered from
any individual, organization, entity, agency, or other
source which may have knowledge concerning any such
items of this information. I have completed this
application of my own free will and hold Midwest
Specialized Transportation, Inc. harmless of all
liability for providing this application for my use.
In connection with
my application for certification (including contract for services)
with you, I understand that consumer reports which may contain
public record information may be requested. These reports may
include the following type of information: names and dates of
previous employers, reason for termination of employment, work
experience, accidents, etc. I further understand that such reports
may contain public record information concerning my driving record,
workers compensation claims, credit, bankruptcy proceedings,
criminal records, etc., from federal, state and other agencies which
maintain such records; as well as information concerning previous
driving record requests made by others from such state agencies, and
state provided driving records.
I AUTHORIZE, WITHOUT
RESERVATION, ANY PARTY OR AGENCY TO FURNISH THE ABOVE-MENTIONED
INFORMATION.
