Apply Now – Nebraska CDL School

21 yrs of age — NO DUI, DWI, Drug Charges, or Violent Offenses — Ability to Pass DOT Drug Screen and Physical — No more than 3 moving Violations — 3 Yrs. Verifiable/Stable Work History.

First Name *

Middle Name

Last Name *

Email *

Date of Birth *

Social Security Number *

Phone *

Best Time to Call

Address *

City *

State

Zip *

How did you hear about us? *

Driver License *

Must have valid Nebraska or TEXAS driver license to apply.

State Issued

License Class *

Expiration Date

Do you have a previous Out-Of-State Driver License *

Which state was your previous driver license from?

Driver License Number:

Employment History #1

EMPLOYER NAME & Job Title 1 *

EMPLOYER FULL ADDRESS 1 *

Address Line 1

Address Line 2

City

State

Zip Code

EMPLOYER PHONE 1 *

START DATE 1 *

END DATE 1 *

Employment History #2

EMPLOYER NAME & Job Title 2

EMPLOYER FULL ADDRESS 2

Address Line 1

Address Line 2

City

State

Zip Code

EMPLOYER PHONE 2

START DATE 2

END DATE 2

Employment History #3

EMPLOYER NAME & Job Title 3

EMPLOYER FULL ADDRESS 3

Address Line 1

Address Line 2

City

State

Zip Code

EMPLOYER PHONE 3

START DATE 3

END DATE 3

Criminal Record

Have you ever been convicted of a felony? *

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? *

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

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

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

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

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

Have you ever been discharged or suspended? *

Do You have any Pending Misdemeanor or Felony Charges? *

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? *

Have you used an illegal substance within the past two years? *

Have you ever failed a drug test or been dependent on an illegal substance? *

Have you served in the United States military? *

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

Additional Comments

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. *

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. *

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. *

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.

PSP Consent Form Regarding Background Reports from the PSP Online Serivce REGARDING BACKGROUND REPORTS FROM THE PSP Online Service In connection with your application for employment with Raider Express (“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. 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. You may challenge the accuracy of the data by submitting a request to https://dataqs.fmcsa.dot.gov. If you challenge crash or inspection information reported by a State, FMCSA cannot change or correct this data. Your request will be forwarded by the DataQs system to the appropriate State for adjudication. 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 Federal Motor Carrier Safety Regulations (FMCSR) violations that have been adjudicated by a court of law will also appear, and remain, on a PSP report. The Prospective Empolyer cannot obtain background reports from FMCSA without your authorization. If you agree that the Prospective Empolyer may obtain such background reports, please read the following and sign below: I authorize Raider Express (“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 authorizing 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. AUTHORIZATION 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 challenge 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. I understand that any crash or inspection in which I was involved will display on my PSP report. Since the PSP report does not report, or assign, or imply fault, I acknowledge it will include all CMV crashes where I was a driver or co-driver and where those crashes were reported to FMCSA, regardless of fault. Similarly, I understand all inspections, with or without violations, will appear on my PSP report, and State citations associated with FMCSR violations that have been adjudicated by a court of law will also appear, and remain, on my PSP report. I have read the above Disclosure Regarding Background Reports provided to me by Prospective Employer and I understand that if I sign this Disclosure and Authorization, 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.

Signature *

I hereby authorize __________________________________ to release all records of employment and work history, including assessments of job performance, ability, fitness and any informationregarding my alcoholand controlled substancetesting or training records to each and every company (or their authorized agents) which may request such information in connection with my Request for Qualification as a driver for said company. I hereby release this company from any and all liability of any type as a result of providing the requested information.

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