Disclosures: Part 1
DISCLOSURE REGARDING BACKGROUND INVESTIGATION CONSENT FORM
Redhawk Coil Tubing, LLC (“the Company”) may obtain information about you from a third-party consumer reporting agency for employment purposes. Thus, you may be the subject of a “consumer report” which may include information about your character, general reputation, personal characteristics, and/or mode of living. These reports may contain information regarding your credit history 1, criminal history, social security verification, motor vehicle records (“driving records”), education or employment history, or other background checks.
These searches will be conducted by:
DISA Global Solutions, 11740 Katy Freeway, Suite 900, Houston, TX 77079
(800) 752-6432
www.disa.com.
DISCLOSURE REGARDING “INVESTIGATIVE CONSUMER REPORT” BACKGROUND INVESTIGATION CONSENT FORM
Redhawk Coil Tubing, LLC (the “Company”), to which you have applied for employment, may request an investigative consumer report about you from a third-party consumer reporting agency, in connection with your employment or application for employment (including independent contractor or volunteer assignments, as applicable). An “investigative consumer report” is a background report that includes information from personal interviews (except in California, where that term includes background reports with or without information obtained from personal interviews). The most common form of an investigative consumer report in connection with your employment is a reference check through personal interviews with sources such as your former employers and associates, and other information sources. The investigative consumer report may contain information concerning your character, general reputation, personal characteristics or mode of living. You may request more information about the nature and scope of an investigative consumer report, if any, by contacting the Company.
You have the right, upon written request made within a reasonable time, to request (1) whether an investigative consumer report has been obtained about you, (2) disclosure of the nature and scope of any investigative consumer report and (3) a copy of your report.
These searches will be conducted by:
DISA Global Solutions, 11740 Katy Freeway, Suite 900, Houston, TX 77079
(800) 752-6432
www.disa.com.
CaliforniaMinnesotaNew YorkOklahomaWashingtonNone of these
NEW YORK RESIDENTS & APPLICANTS ONLY
Upon request, you will be informed whether or not a consumer report was requested by the Company, and if such report was requested, informed of the name and address of the consumer reporting agency that furnished the report. You have the right to inspect and receive a copy of any investigative consumer report requested by the Company by contacting the consumer reporting agency directly. By signing the Acknowledgement and Authorization for Consumer Report, you acknowledge receipt of Article 23-A of the New York Correction Law.
WASHINGTON STATE RESIDENTS & APPLICANTS ONLY
You have the right to request from the consumer reporting agency a written summary of your rights and remedies under the Washington Fair Credit Reporting Act.
Los AngelesSan FranciscoNeither of these
LOS ANGELES RESIDENTS & APPLICANTS ONLY
Please click here to receive a copy of the Notice to Applicants & Employees Fair Chance Initiative for Hiring Ordinance.
SAN FRANCISCO RESIDENTS & APPLICANTS ONLY
Please click here to receive a copy of the San Francisco Fair Chance Ordinance Notice.
NOTICE REGARDING BACKGROUND CHECKS PER CALIFORNIA LAW
Redhawk Coil Tubing, LLC (the “Company”) intends to obtain information about you for employment screening purposes from a consumer reporting agency. Thus, you can expect to be the subject of “investigative consumer reports” obtained for employment purposes. Such reports may include information about your character, general reputation, personal characteristics and mode of living. With respect to any investigative consumer report from an investigative consumer reporting agency (“ICRA”), the Company may investigate the information contained in your employment application and other background information about you, including but not limited to obtaining a criminal record report, verifying references, work history, your social security number, your educational achievements, licensure, and certifications, your driving record (which may contain your photograph, social security number, driver identification number, name, address, telephone number, and medical or disability information), and other information about you, and interviewing people who are knowledgeable about you. The results of this report may be used as a factor in making employment decisions.
These searches will be conducted by:
DISA Global Solutions, 11740 Katy Freeway, Suite 900, Houston, TX 77079
(800) 752-6432
www.disa.com.
The Company agrees to provide you with a copy of an investigative consumer report when required to do so under California law.
Under California Civil Code section 1786.22, you are entitled to find out what is in the ICRA’s file on you with proper identification, as follows:
- In person, by visual inspection of your file during normal business hours and on reasonable notice. You also may request a copy of the information in person. The ICRA may not charge you more than the actual copying costs for providing you with a copy of your file.
- A summary of all information contained in the ICRA’s file on you that is required to be provided by the California Civil Code will be provided to you via telephone, if you have made a written request, with proper identification, for telephone disclosure, and the toll charge, if any, for the telephone call is prepaid by or charged directly to you.
- By requesting a copy be sent to a specified addressee by certified mail. ICRAs complying with requests for certified mailings shall not be liable for disclosures to third parties caused by mishandling of mail after such mailings leave the ICRAs.
“Proper Identification” includes documents such as a valid driver’s license, social security account number, military identification card, and credit cards. Only if you cannot identify yourself with such information may the ICRA require additional information concerning your employment and personal or family history in order to verify your identity.
The ICRA will provide trained personnel to explain any information furnished to you and will provide a written explanation of any coded information contained in files maintained on you. This written explanation will be provided whenever a file is provided to you for visual inspection. You may be accompanied by one other person of your choosing, who must furnish reasonable identification. An ICRA may require you to furnish a written statement granting permission to the ICRA to discuss your file in such person’s presence.
Please check this box if you would like to receive a copy of an investigative consumer report at no charge if one is obtained by the Company whenever you have a right to receive such a copy under California law.
A SUMMARY OF YOUR RIGHTS UNDER THE FAIR CREDIT REPORTING ACT
Please click HERE to read about your rights under the Fair Credit Reporting Act.
ACKNOWLEDGEMENT AND AUTHORIZATION FOR BACKGROUND INVESTIGATION CONSENT FORM
By checking the box below, I acknowledge receipt of the DISCLOSURE REGARDING BACKGROUND INVESTIGATION and the separate document entitled A SUMMARY OF YOUR RIGHTS UNDER THE FAIR CREDIT REPORTING ACT, and certify that I have read and understand both of those documents. I hereby authorize the obtaining of “consumer reports” and/or “investigative consumer reports” by Redhawk Coil Tubing, LLC (“Company”) at any time after receipt of this authorization and throughout my employment, if applicable. To this end, I hereby authorize any law enforcement agency, administrator, state or federal agency, institution, school or university (public or private), information service bureau, employer, or insurance company to furnish any and all background information requested by DISA Global Solutions, 11740 Katy Freeway, Suite 900, Houston, TX 77079, (800) 752-6432, www.disa.com and/or the Company.
I understand that a “consumer report” may consist of my driving history (“MVR”) from a state motor vehicle records agency or Department of Motor Vehicles, and authorize the Company to obtain my MVR(s), which may contain personal information about me, such as my photograph, social security number, driver identification number, name, address, telephone number, and medical or disability information.
Driver Disclosure: Part 1
CONSUMER REPORT AND INVESTIGATIVE CONSUMER REPORT DISCLOSURE FOR EMPLOYMENT PURPOSES
In connection with your employment or application for employment (including contract for services ) and in accordance with applicable laws, the Company, DISA Global Solutions may obtain or assemble consumer reports and/or investigative consumer reports (collectively, “Reports” ) which may include information about you related to: previous employment (including employers , dates of employment, salary informa- tion, reasons for termination, etc. ), accident history, safety performance history/violation information, academic history, verification of references and other information supplied by applicant, professional credentials, drug/alcohol use in violation of law and/or company policy, driving record, workers’ compensation claims, credit history, credit worthiness, credit capacity, bankruptcy filings, criminal history records, information about your character, general reputation, personal characteristics and mode of living (collectively, “Information”). Information may be obtained from government agencies, educational institutions, DISA Global Solutions clients, personal references, personal interviews and other information suppliers (collectively,
“Suppliers”).
Upon providing proper identification and complying with any applicable legal requirements, you have the right to request the nature and substance of all information in DISA Global Solutions’s files pertaining to you at the time of your request, including but not limited to: (i) whether any Reports have been provided by DISA Global Solutions to other parties; (ii) identification of any Suppliers utilized by DISA Global Solutions in compiling such Reports; (iii) identification of any recipients of Reports furnished by DISA Global Solutions within the two (2) year period preceding your request. DISA Global Solutions may be contacted by 11740 Katy Freeway, Suite 900, Houston,TX 77079, (800) 752-6432, www.disa.com.
AUTHORIZATION FOR RELEASE OF INFORMATION (FOR EMPLOYMENT PURPOSES)
hereby authorize the Company, DISA Global Solutions to receive information and disclose such information to its customers for the purpose of making a determination as to my eligibility for employment, promotion, retention, or other lawful purpose. If hired or contracted, I authorize the Company and DISA Global Solutions to retain this document on file to act as ongoing authorization for the procurement and possession of Reports at any time during my employment or contract period. I fully release DISA Global Solutions and Suppliers from all claims of damages related to the investigation of my background and provision of information as set forth in this disclosure and authorization. I agree that information in the Company’s possession and my employment history with the Company if I am hired, may be supplied by the Company to other motor carriers for legally permissible purposes; provided, such information will not include the Drug and Alcohol information set forth in Part II below, unless I have given a separate specific consent for the Company to share such information.
FM CSA Notification of Driver Rights
In compliance with 49 CFR Part 391.23 (i) you have certain rights regarding the performance history information that will be provided to prospective employers. I) You have the right to review the information provided by previous employers. II) You have a right to have errors in the information corrected by the previous employer and for that previous employer to re-send the corrected information to prospective employers. III) You have the right to have a rebuttal statement attached to the alleged erroneous information, if the previous employer and the driver cannot agree on the accuracy of the information. (2) Drivers who have previous Department of Transportation regulated employment history in the preceding three years, and wish to review previous employer-provided investigate information must submit a written request to the prospective employer, which may be done at any time, including when applying, or at late as 30 days after being employed or being notified of denial of employment. The prospective employer must provide this information to the applicant within five (5) business days of receiving the written request. If the prospective employer has not yet received the requested information from the previous employer(s), then the five-business days deadline will begin when the prospective employer receives the requested safety performance history information. If the driver has not arranged to pick up or receive the requested records within thirty (30) days of the prospective employer making them available. The prospective motor carrier may consider the driver to have waived his/her request to review the records.
Driver Disclosure: Part 2
DISCLOSURE AND AUTHORIZATION FOR RELEASE OF INFORMATION FOR EMPLOYMENT PURPOSES – 49 CFR PART 391.23, DOT DRUG AND ALCOHOL TESTING
In accordance with DOT Regulation 49 CFR Part 391.23, [ hereby authorize release of my DOT-regulated drug and alcohol testing records by the DOT-regulated employer(s) listed below to the Company. I understand that information/ documents released pursuant to this Part I is limited to the following DOT-regulated testing items, including pre-employment testing results, occurring during the previous three (3) years: (i) alcohol tests with a result of 0.04 or higher; (ii) verified positive drug tests; (iii) refusals to be tested (including adulterated and/or substituted tests); (iv) other violations of DOT drug and alcohol testing regulations (i.e., violations of 49 CFR 382 Subpart B); (v) information obtained from previous employers of a drug and alcohol rule violation; and (vi) any documentation of completion of the return-of-duty process following a rule violation.
In any company listed below furnishes the Company with information concerning items (i) through (vi) above, I also authorize such company to furnish the following information, if applicable: (i) dates of my negative drug and/or alcohol tests and/or tests with results below 0.04 during the previous three (3) years; and (iii) the name and phone number of any substance abuse professional who evaluated me during the previous three (3) years.
List all DOT-regulated employers you have applied with and/or worked for in a safety-sensitive function during the previous three (3) years. If necessary, attach additional pages, including the date, your name, social security number and signature.
Previous DOT-Regulated Employers
Applicant Certification
By checking the box below, I certify that:
- This application for employment/contract was completed by me and that all entries on it and the information contained within it are true and correct to the best of my knowledge.
- As required by §383.21 of the FMCSR’s, I only have one motor vehicle operator’s license.
Furthermore, I authorize you (the Company or agencies) to make such investigations and inquiries of my personal, employment, financial, or medical history and other related matters as may be necessary in arriving at an employment/contract decision. I hereby release any and all of; the employers, the schools, the health care providers, the Company and their subsidiaries, as well as the other persons associated with this application for employment/contract and the subsequent processes and procedures from all liability in response to inquiries and the releasing of information in connection with my application. In the event of employment/contract, I understand that false or misleading information given in my application or interview(s) may be considered fraud and could be construed as criminal, and may be grounds for termination and permanent discharge from this company. I understand that I am required to abide by all rules and regulations of the Company as outlined in the company policies and statements.
I understand that information I provide regarding current and/or previous employers may be used, and those employer(s) will be contacted, for the purpose of investigating my safety performance history as required by 49 CFR § 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 resend the corrected information to the prospective employer; and
- 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.
The Company is an equal opportunity employer and does not discriminate on the basis of race, color, religion, gender, age, sexual orientation, national origin or ancestry, physical or mental stability, marital status, pregnancy, veteran status, medical condition, or any other protects status as defined by the law.
I Agree
