Name

Street Address

City

State

ZIP Code

Phone Number

Email Address

Date of Birth MM/DD/YYYY

Drivers License State

Divers License Number

Social Security Number

CDL Endorsements

How Much OTR Experience? (In Months)

Number of Traffic Citations in Past 5 years

Number of Motor Vehicle Accidents in Past 5 Years

Please list your Employment for the Past 10 Years

Current or Last Employer

Company Name

Company Address

City, State, ZIP

Phone Number

Dates Employed From MM/DD/YYYY

Dates Employed To MM/DD/YYYY

Position Held

Number of States

Reason for leaving

Second Previous Employer

Company Name

Company Address

City, State, ZIP

Phone Number

Dates Employed From MM/DD/YYYY

Dates Employed To MM/DD/YYYY

Position Held

Number of States

Reason for leaving

Third Previous Employer

Company Name

Company Address

City, State, ZIP

Phone Number

Dates Employed From MM/DD/YY

Dates Employed to MM/DD/YY

Position Held

Number of States

Reason for leaving

I AUTHORIZE, WITHOUT RESERVATION, ANY PARTY OR AGENCY CONTACTED BY THE UNIVERSE COMPANY, OR BY HIRERIGHT INC TO FURNISH THE ABOVE INFORMATION.

I have the right to make a request to HireRight Inc, with proper identification, to request the nature and substance of all information in its files on me at the time of my request.

I hereby authorize procurement of the consumer reports. If hired [or contracted], this authorization shall remain on file and shall serve as ongoing authorization for you to procure consumer reports during my employment [or contract] period.

In connection with my application for employment [including contractor services] with you, I understand that consumer reports which contain public record information may be requested from HireRight Inc., Irvine, CA.

These reports may include the following types of information: Names and Dates of previous employers, reason for termination of employment, work experience, accidents, etc.

I further understand that reports may contain public record information concerning my driving record, worker compensation claims, credit history, bankruptcy proceedings, criminal records, etc. from Federal, State, and other agencies

which maintain such records, as well as information from HireRight Inc. concerning previous driving record requests from such state agencies and state provided driving records.