Houma, LA 70364
Closed on Weekends
DOT Regulation 49 CFR Part 40.25I consent and authorize my PREVIOUS EMPLOYER to furnish the following information:
I authorize my previous employer to speak with, send documentation to, and otherwise communicate with CTCO regarding the information contained in the section below. I authorize my previous employer to release to CTCO records and information relating to any completion of the DOT return-to-work process:
I hereby declare that I am not disabled in any way which would prevent me from steadily performing all the work applied for in this application. I further declare that the answers to the questions on the opposite side are correct and that any misstatement of fact or omission should be cause for dismissal or rejection. I authorize the company to contact any of my previous employers as well as any reference source
in order to verify the facts and information I have furnished regarding my qualifications and character. I hereby authorize any person(s) having knowledge thereof to provide such information to the company, and I hereby release from liability and agree to hold harmless any person that furnishes such information in good faith. I agree that I will submit to a physical, urinalysis, and/or blood or other examination requested by the company at any time prior to or subsequent to my employment. I authorize the company to supply my employment record in whole or part and in confidence to any employer insurance agency, or other party with legal and proper interest, and I hereby release the company from any liability and agree to hold harmless any employee of the company who furnishes such information. I further understand that my employment is for no fixed time and may be discontinued with or without cause or notice by myself or the company. I understand that no employee or officer or agent of the company may bind it by oral or printed statements, including handbooks, benefit books, or bulletins, contrary to the above. Finally I understand that no firearms, alcohol, or drugs are permitted on company premises, and that either being under the influence of alcohol or have identifiable traces of illicit drugs in my system during working hours is strictly prohibited. If medication is prescribed by doctor, I am required to notify management, in writing, of the specific medical problem and the exact drug that has been prescribed, immediately upon reporting to work.
Under the provisions of the Fair Credit Reporting Act, 15 U.S.C. Sec. 1681, et. seq. notice is hereby given that an investigative consumer report may be made which may include information pertaining to your credit worthiness, character, general reputation, personal characteristics, and mode of living, which will be used for employment purposes. An investigation into your workers’ compensation or industrial accident background may also be conducted.
You are further advised under said Act you have the right to request the company to make a complete and accurate disclosure of the nature and scope of the investigation requested by the company. Your request must be in writing and submitted within a reasonable period of time after your application. The company shall respond in writing, mailed or otherwise delivered, to you no later than five days after the date on which the request for such disclosure was received from you or such investigative consumer report was first requested by the company, whichever is the later.
I have carefully read the above provisions and, having had the opportunity to ask question about them, agree to the terms printed on this form.
READ CAREFULLY BEFORE SIGNING
BY MY SIGNATURE BELOW, I ACKNOWLEDGE THAT I HAVE READ AND UNDERSTOOD ALL OF THE ABOVE STATEMENTS.
EQUAL OPPORTUNITY EMPLOYER M/F/H
MAIN IRON WORKS | HOUMA, LOUISIANA