REQUEST OF INFORMATION RELEASE
AUTHORIZATION
If you agree that the Prospective Employer may obtain such background reports, please read the following and sign below:
I authorize Woodland Logistics Inc. (“Prospective Employer”) to access the FMCSA Pre-Employment Screening
Program (PSP) system to seek information regarding my commercial driving safety record and information regarding my safety
inspection history. I understand that I am authorizing the release of safety performance information including crash data from the
previous five (5) years and inspection history from the previous three (3) years. I understand and acknowledge that this release of
information may assist the Prospective Employer to make a determination regarding my suitability as an employee.
I further understand that neither the Prospective Employer nor the FMCSA contractor supplying the crash and safety information has
the capability to correct any safety data that appears to be incorrect. I understand I may challenge the accuracy of the data by
submitting a request to https://dataqs.fmcsa.dot.gov. If I challenge crash or inspection information reported by a State, FMCSA cannot
change or correct this data. I understand my request will be forwarded by the DataQs system to the appropriate State for adjudication.
I understand that any crash or inspection in which I was involved will display on my PSP report. Since the PSP report does not report,
or assign, or imply fault, I acknowledge it will include all CMV crashes where I was a driver or co-driver and where those crashes
were reported to FMCSA, regardless of fault. Similarly, I understand all inspections, with or without violations, will appear on my
PSP report, and State citations associated with FMCSR violations that have been adjudicated by a court of law will also appear, and
remain, on my PSP report.
I have read the above Disclosure Regarding Background Reports provided to me by Prospective Employer and I understand that if I
sign this Disclosure and Authorization, Prospective Employer may obtain a report of my crash and inspection history. I hereby
authorize Prospective Employer and its employees, authorized agents, and/or affiliates to obtain the information authorized above.
Date: __________________________________
Signature
___________________________________________________ Name (Please Print)
NOTICE: This form is made available to monthly account holders by NIC on behalf of the U.S. Department of Transportation, Federal
Motor Carrier Safety Administration (FMCSA). Account holders are required by federal law to obtain an Applicant’s written or
electronic consent prior to accessing the Applicant’s PSP report. Further, account holders are required by FMCSA to use the language
contained in this Disclosure and Authorization form to obtain an Applicant’s consent. The language must be used in whole, exactly as
provided. Further, the language on this form must exist as one stand-alone document. The language may NOT be included with other
consent forms or any other language.
NOTICE: The prospective employment concept referenced in this form contemplates the definition of “employee” contained at 49
C.F.R. 383.5.
LAST UPDATED 08/06/2021
