Please list three professional references, not related to you, whom you have known for at least 1 year.
Disclaimer and Signature
I certify that my answers are true and complete to the best of my knowledge.
If this application leads to employment, I understand that false or misleading information in my application or
interview may result in my release.
In consideration of my employment, I agree to conform to the company’s rules and regulations, and I agree that
my employment and compensation can be terminated, with or without cause, and with or without notice, at any
time, at either my or the company’s option.
I also understand and agree that the terms and conditions of my employment may be changed, with or without
cause, and with or without notice at any time by the company.
I understand that no company representative, other than its president, and then only when in writing and signed
by the president, has any authority to enter into any agreement for employment for any specific period of time, or
to make any agreement contrary to the foregoing.
Consent for Check of Driving Record
Applicants please read carefully and fill out Sections 1 and 2.
I hereby authorize you to release information to Pickett Industries, LLC for the purpose of investigation as
required by Section 391.23 of the Federal Motor Carrier Safety Regulations. You are released from any and all
liability which may result from furnishing such information.
Fair Credit Reporting Act Disclosure Statement
In accordance with the provisions of Section 604(b) (2) (A) of the Fair Credit Reporting Act, Public Law 91-508, as
amended by the Consumer Credit Reporting Reform Act of 1996 (Title II, Subtitle D, Chapter 1, of Public Law
104-208), you are being informed that reports verifying your previous employment, previous drug and alcohol test
results, and your driving record may be obtained on you for employment purposes. These reports are required by
Section 382.413, 391.23, and 391.25 of the Federal Motor Carrier Safety Regulations.
Criminal Record Consent
I hereby give my full consent to Pickett Industries, LLC to obtain any
and all of my available criminal records. I understand that this consent is a condition of my employment with
Pickett Industries, LLC and that refusal to give consent is reason for immediate dismissal. I also understand that
any findings not in compliance with Pickett Industries, LLC policy will be reason for dismissal.