By initialing and clicking below to submit my information, I:

I certify that this questionnaire was completed/reviewed by me, and the information is true and complete to the best of my knowledge.

I hereby authorize the release of all records regarding the job performance from prior employers or parties with whom I have contracted, and I release them from any and all liability regarding information they provide.

I authorize Monsey One Trucking to investigate my background, any possible criminal record, and prior work history, and agree that any misrepresentation or omission of facts is a legitimate cause for denial of certification or cancellation of certification. This is a questionnaire for certification, not employment.

I also authorize the release of information to the Safety Qualification Technician at Monsey One Trucking concerning (i) all positive drug test results during the past three (3) years; (ii) all alcohol test results of 0.04 or greater during the past three (3) years; (iii) all alcohol test results of 0.02 or greater but less than 0.04 during the past three (3) years; (iv) all instances in which I refused to submit to a DOT required drug and/or alcohol test during the past three (3) years; and (v) all other violations of DOT agency drug and alcohol testing regulations This is in accordance with Federal Motor Carrier Safety Regulations 49 CFR§§§§40.25, 40.321, 382.405, and 382.413.

Furthermore, I submit that I have been expressly notified of my rights regarding the investigative information provided to Monsey One Trucking as outlined in FMCSR §391.23(i), which includes:

The right to review information provided by previous employers.

The right to have errors in the information corrected by the previous employer and for that employer to re-send that corrected information to Monsey One Trucking.

The right to have a rebuttal statement attached to the alleged erroneous information if the previous employer and I cannot agree on the accuracy of the information.

I understand that in order to receive such investigative information I must submit a written request per §391.23(i) to Dart or

Mainstream at any time prior to or within 30 days after being notified of approval or denial of qualification for certification.