Pace Drivers **-**-**** **:**:**PM CDT
Cleveland, OH 44109
IntelliApp
Thank you for your interest in Pace Drivers. To apply for a driving position, please
complete our online application for employment. Incomplete information will delay the
processing of your application or prevent it from being submitted.
In compliance with Federal and State equal employment opportunity laws, qualified
applicants are considered for all positions without regard to race, color, religion, sex,
national origin, age, marital status, veteran status, non-job related disability, or any other
protected group status.
Personal Information
Referral Code: Indeed
Name Terry Walker
Residence 3 years or longer (If No, Yes
previous addresses shown below)
Current Address 2383 Noble Rd
Address 2 2610 Idlewood
City, State/Province Zip/Postal Cleveland Hts, OH 44118
Country United States
SSN/SIN 7152
Date of Birth
Primary Phone 215-***-****
Cell Phone 215-***-****
Preferred method of contact Cell Phone
Best time to contact you Any
Email ac0r5u@r.postjobfree.com
Yes, I want to receive information and Yes
communications from Pace Drivers
concerning future opportunities or
promotions.
Yes, I want to receive text messages from Yes
Pace Drivers. *By participating, you
consent to receive text messages sent by
an automatic telephone dialing system.
Consent to these terms is not a condition
of hire. You may opt out at any time by
texting STOP to unsubscribe. Message
and Data Rates May Apply.
Company Questions
GENERAL INFORMATION
What position are you applying for? Company Driver
If you answered "Owner Operator" or No
"Fleet Owner", select yes.
EQUIPMENT (OWNER/OPERATORS ONLY)
Equipment Description (Tractor):
Type:
Year:
Make:
Model:
Color:
VIN:
Weight
Mileage
Fifth Wheel Height
What city/state are you applying for? Twinsburg
Are you legally eligible for employment in Yes
the United States?
Are you currently employed? No
What date did your last employment end? 1/25/2017
Do you read, write, and speak English? Yes
Have you ever worked for this company No
before?
Enter start and end dates, location,
position, rate of pay, and reason for
leaving:
Do you have a current TWIC card? Yes
Expiration date: 08/31/2018
Please enter the names of any relatives
employed here:
Have you ever been known by any other No
name?
Enter name:
How did you hear about us? Indeed
If "Driver Referral", please enter the
driver's name
If "Other", please explain
In case of Emergency, notify (list name, 21595 Lakeshore euclid ohio 44124. Kiya
address, and phone): Walker my daughter.
DRIVING EXPERIENCE
For each class of equipment, enter type of equipment (van, reefer, tank, etc.), start and
end dates, and approximate number of total miles. If no experience in a class, enter
"NONE".
Straight Truck For 6 months at jrl.king.over 3000 miles in
6 months.
Tractor and Semi-Trailer None
Tractor - Two Trailers None
Other Tandem garagbe trucks tandem snow plow
truck tandem dump trucks.
Which safe driving awards do you hold City of Cleveland for snow plowing an
and from whom? waste collection.
EDUCATION
List highest grade completed: Grade 12
List last school attended (name, city, and Shaw high school
state):
PERSONAL REFERENCES
List name, address, city, state, phone number, and relationship:
First Reference: Michael Nunn. Head fotman in waste
collection.city of Cleveland. 316-***-****.
Second Reference: Jacquelyn Salters.retired secretary at
ODOT.for roads and
transportation.216-***-****.
Licenses
License Number 233
State/Province OH
Country United States
License Class Class B
License Expiration Date 07-31-2018
Physical Expiration Date 08-05-2018
Current License Yes
Commercial Driver License Yes
Endorsements
Tanker Endorsement No
HAZMAT Endorsement No
X Endorsement No
Doubles Triples Endorsement No
Other Endorsement Yes
Employment / Unemployment
Unemployment
Start Date 02-2017
End Date 03-2017
Comment Looking for work.
JRL.King transportaion
Company JRL.King transportaion
Start Date 09-2016
End Date 01-2017
Address 21404 north lane.
City, State/Province Zip/Postal Bedford Hts, OH 44146
Country United States
Phone 440201938
Position Held Truck drivet
Reason for leaving? Lower pay an did not tell me was paying
the menore.
Were you terminated/discharged/laid off? No
Is this your current employer? No
May we contact this employer at this time? Yes
Did you operate a commercial motor Yes
vehicle?
Were you subject to the Federal Motor Yes
Carrier or Transport Canada Safety
Regulations while employed/contracted by
this employer/contractor?
Did you perform any safety sensitive Yes
functions in this job, regulated by DOT,
and subject to drug and alcohol testing?
Areas Driven Ohio
Miles driven weekly 500-1000
Pay Range (cents/mile) $90.a day
Most common truck driven Class B Vehicle
Most common trailer Other
Trailer length 31 feet or less
JRL.King transportion
Company JRL.King transportion
Start Date 08-2016
End Date 01-2017
Address 21404 north lane.
City, State/Province Zip/Postal Bedford Hts, OH 44146
Country United States
Phone 440201938
Position Held Delivery truck driver
Reason for leaving? Found out he lowred my pay an did not let
me be aware was pa
Were you terminated/discharged/laid off? No
Is this your current employer? No
May we contact this employer at this time? Yes
Did you operate a commercial motor Yes
vehicle?
Were you subject to the Federal Motor Yes
Carrier or Transport Canada Safety
Regulations while employed/contracted by
this employer/contractor?
Did you perform any safety sensitive Yes
functions in this job, regulated by DOT,
and subject to drug and alcohol testing?
Areas Driven All ohio
Miles driven weekly 1000-1500
Pay Range (cents/mile) $90. S day
Most common truck driven Class B Vehicle
Most common trailer Container
Trailer length 31 feet or less
Unemployment
Start Date 02-2014
End Date 08-2016
Comment I broke my ankle feb 02/14/2014 had
surgery an then alot of thearpy.
Motor Vehicle Record
1. Has any license, permit or privilege ever No
been denied, suspended or revoked for
any reason?
2. Have you ever been convicted of driving No
during license suspension or revocation, or
driving without a valid license or an expired
license, or are any charges pending?
3. Have you ever been convicted for any No
alcohol or controlled substance related
offense while operating a motor vehicle, or
are any charges pending?
4. Have you ever been convicted for No
possession, sale or transfer of an illegal
substance (including but not limited to,
marijuana, amphetamines, or derivatives
thereof) while on duty, or are any charges
pending?
5. Have you ever been convicted of No
reckless driving, careless driving or
careless operation of a motor vehicle, or
are any charges pending?
6. Have you ever tested positive, or No
refused to test on a pre-employment drug
or alcohol test by an employer to whom
you applied, but did not obtain
safety-sensitive transportation work
covered by DOT agency drug and alcohol
testing rules in past three years, or have
you ever tested positive or refused to test
on any DOT-mandated drug or alcohol
test?
Vehicle Accident Record
Were you involved in any accidents/incidents with any vehicle in the last 5 years (even
if not at fault)?
No Accidents
Traffic Convictions \ Violations
Have you had any moving violations or traffic convictions in the past 3 years?
No Violations
Criminal Record
Have you ever been convicted of a crime? No
Do you have any deferred prosecutions? No
Do you have criminal charges pending? No
Have you ever pled "guilty" to, been No
convicted of, or pled "no contest" to a
felony?
If you have any felony convictions, do you No
currently hold a minister's permit to enter
or exit Canada?
Have you, within the last five years, pled No
"guilty" to, been convicted of, had
prosecution deferred in connection with, or
pled "no contest" to a misdemeanor?
Federal FCRA Summary of Rights Acknowledgment
By checking this box, I acknowledge that I Yes
have read and understand the Summary of
Rights.
Drug and Alcohol Release
I agree with the above language Yes
Certification Release
I agree with the above language Yes
PSP Release
I agree with the above language Yes
User Requested Copy
User requested a copy to be sent to this Yes
email address
ac0r5u@r.postjobfree.com.
By my check of this box, I represent that I Yes
understand and agree to the above and
that I intend to execute this document by
electronic signature in checking this box.
Signature
Full Name Terry Walker
IP Address 172.58.201.66
Signature Date/Time 03-17-2017 12:58 PM
This certifies that this application was completed by me, and that all
entries on it and information in it are true and complete to the best of
my knowledge.
Signed Date: 03-17-2017 12:58 PM
Signed:
8
AUTHORIZATION FOR CONSUMER REPORTS
I hereby authorize Company to obtain the consumer reports described above about me.
Printed Name: Terry Walker
2383 Noble Rd
Terry Walker
2610 Idlewood
Social Security #: Cleveland Hts, OH 44118
7152 215-***-****
Gender:
Signed Date: 03-17-2017
9
IMPORTANT DISCLOSURE
REGARDING BACKGROUND REPORTS FROM THE PSP Online Service
In connection with your application for employment with Pace Drivers ("Prospective Employer"), Prospective Employer, its employees, agents or
contractors may obtain one or more reports regarding your driving, and safety inspection history from the Federal Motor Carrier Safety Administration
(FMCSA).
When the application for employment is submitted in person, if the Prospective Employer uses any information it obtains from FMCSA in a decision to
not hire you or to make any other adverse employment decision regarding you, the Prospective Employer will provide you with a copy of the report
upon which its decision was based and a written summary of your rights under the Fair Credit Reporting Act before taking any final adverse action. If
any final adverse action is taken against you based upon your driving history or safety report, the Prospective Employer will notify you that the action
has been taken and that the action was based in part or in whole on this report.
When the application for employment is submitted by mail, telephone, computer, or other similar means, if the Prospective Employer uses any
information it obtains from FMCSA in a decision to not hire you or to make any other adverse employment decision regarding you, the Prospective
Employer must provide you within three business days of taking adverse action oral, written or electronic notification: that adverse action has been
taken based in whole or in part on information obtained from FMCSA; the name, address, and the toll free telephone number of FMCSA; that the
FMCSA did not make the decision to take the adverse action and is unable to provide you the specific reasons why the adverse action was taken; and
that you may, upon providing proper identification, request a free copy of the report and may dispute with the FMCSA the accuracy or completeness of
any information or report. If you request a copy of a driver record from the Prospective Employer who procured the report, then, within 3 business days
of receiving your request, together with proper identification, the Prospective Employer must send or provide to you a copy of your report and a
summary of your rights under the Fair Credit Reporting Act.
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. You may challenge the accuracy of the data by submitting a request to https://dataqs.fmcsa.dot.gov. If you challenge
crash or inspection information reported by a State, FMCSA cannot change or correct this data. Your request will be forwarded by the DataQs system
to the appropriate State for adjudication.
Any crash or inspection in which you were involved will display on your PSP report. Since the PSP report does not report, or assign, or imply fault, it
will include all Commercial Motor Vehicle (CMV) crashes where you were a driver or co-driver and where those crashes were reported to FMCSA,
regardless of fault. Similarly, all inspections, with or without violations, appear on the PSP report. State citations associated with Federal Motor Carrier
Safety Regulations (FMCSR) violations that have been adjudicated by a court of law will also appear, and remain, on a PSP report.
The Prospective Employer cannot obtain background reports from FMCSA without your authorization.
AUTHORIZATION
If you agree that the Prospective Employer may obtain such background reports, please read the following and sign below:
I authorize Pace Drivers ("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.
Printed Name:
Terry Walker
Signed Date: 03-17-2017
OTHER DISCLOSURES, ACKNOWLEDGMENTS & AUTHORIZATIONS REGARDING
BACKGROUND INVESTIGATION FOR EMPLOYMENT PURPOSES
Disclosures
Investigative Consumer Report:
Pace Drivers (the "Company") may request an investigative consumer report about you from HireRight, Inc. ("HireRight"), a 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 which is checking personal or professional references 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, mode of living, or credit standing. You may request more information about the
nature and scope of an investigative consumer report, if any, by contacting the Company.
Ongoing Authorization:
If the Company hires you or contracts for your services, the Company may obtain additional consumer reports and investigative consumer
reports about you without asking for your authorization again, throughout your employment or your contract period, as allowed by law.
Additional State Law Notices:
Please see the "Additional State Law Notices" for California, Massachusetts, Minnesota, New Jersey, New York, and Washington that are
provided below, as applicable. A California disclosure and summary of your rights under California Civil Code Section 1786.22, and a copy
of New York Article 23-A, are being provided to you separately.
Summary of Rights under the Fair Credit Reporting Act:
A summary of your rights under the Fair Credit Reporting Act is being provided to you separately.
San Francisco Fair Chance Ordinance Official Notice:
A copy of the San Francisco Fair Chance Ordinance Official Notice is being provided to you separately.
HireRight Privacy Policy:
Information about HireRights privacy practices is available at www.hireright.com/Privacy-Policy.aspx.
Acknowledgments & Authorization
I acknowledge that I have received and carefully read and understand the separate "Disclosure and Authorization Regarding Background
Investigation for Employment Purposes"; and the separate "Summary of Rights under the Fair Credit Reporting Act" that have been
provided to me by the Company. I also acknowledge receipt of and that I have carefully read and understand (as applicable), the separate
California Disclosure and Summary of Rights under California Civil Code Section 1786.22; the separate New York Article 23-A; and the
separate San Francisco Fair Chance Ordinance Official Notice that have been provided to me.
By my signature below, I authorize the preparation of background reports about me, including background reports that are "investigative
consumer reports" by HireRight, and to the furnishing of such background reports to the Company and its designated representatives and
agents, for the purpose of assisting the Company in making a determination as to my eligibility for employment (including independent
contractor or volunteer assignments, as applicable), promotion, retention or for other lawful employment purposes. I understand that if the
Company hires me or contracts for my services, my consent will apply, and the Company may, as allowed by law, obtain from HireRight
(or from a consumer reporting agency other than HireRight) additional background reports pertaining to me, without asking for my
authorization again, throughout my employment or contract period.
I understand that if the Company obtains a credit report about me, then it will only do so where such information is substantially related to
the duties and responsibilities of the position in which I am engaged or for which I am being evaluated.
I understand that information contained in my employment (or contractor or volunteer) application, or otherwise disclosed by me before or
during my employment (or contract or volunteer assignment), if any, may be used for the purpose of obtaining and evaluating background
reports on me. I also understand that nothing herein shall be construed as an offer of employment or contract for services.
I understand that the information included in the background reports may be obtained from private and public record sources, including
without limitation and as appropriate: government agencies and courthouses; educational institutions; and employers. Accordingly, I
hereby authorize all of the following, to disclose information about me to the consumer reporting agency and its agents: law enforcement
and all other federal, state and local government agencies and courts; educational institutions (public or private); testing agencies;
information service bureaus; credit bureaus and other consumer reporting agencies; other public and private record/data repositories;
motor vehicle records agencies; my employers; the military; and all other individuals and sources with any information about or concerning
me. The information that can be disclosed to the consumer reporting agency and its agents includes, but is not limited to, information
concerning my: employment and earnings history; education, credit, motor vehicle and accident history; drug/alcohol testing results and
history; criminal history; litigation history; military service; professional licenses, credentials and certifications; social security number
verification; address and alias history; and other information.
By my signature below, I also promise that the personal information I provide with this form or otherwise in connection with my background
investigation is true, accurate and complete, and I understand that dishonesty or material omission may disqualify me from consideration
for employment. I agree that a copy of this document in faxed, photocopied or electronic (including electronically signed) form will be valid
like the signed original. I further acknowledge that I have received additional state law notices that I have reviewed and read.
Printed Name: Terry Walker Signed Date: 03-17-2017
Social Security #: 7152
Signed:
12
Additional State Law Notices
Please also note the following:
CALIFORNIA: Pursuant to section 1786.22 of the California Civil Code, you may view the file maintained on you by the consumer
reporting agency during normal business hours. You may also obtain a copy of this file, upon submitting proper identification and paying
the actual copying costs, by appearing at the consumer reporting agency's offices in person, during normal business hours and on
reasonable notice, or by certified mail. You may also receive a summary of the file by telephone, upon submitting proper identification and
written request. The consumer reporting agency has trained personnel available to explain your file to you, including any coded
information, and will provide a written explanation of any coded information contained in your file. If you appear in person, you may be
accompanied by one other person, provided that person furnishes proper identification. "Proper identification" includes documents such as
a valid driver's license, social security account number, military identification card, and credit cards. If you cannot identify yourself with
such information, the consumer reporting agency may require additional information concerning your employment and personal or family
history to verify your identity.
HireRight, Inc. ("HireRight") will prepare the background report for the Company. HireRight is located and can be contacted at 3349
Michelson Drive, Suite 150, Irvine, CA 92612, 800-***-****. Information about HireRight's privacy practices is available at
www.hireright.com/Privacy-Policy.aspx.
MASSACHUSETTS: Upon request to the Company, you have the right to know whether the Company requested an investigative
consumer report about you and, upon written request to the Company, you have the right to receive a copy of any such report. You also
have the right to ask the consumer reporting agency (e.g., HireRight) for a copy of any such report.
MINNESOTA: You have the right in most circumstances to submit a written request to the consumer reporting agency (e.g., HireRight) for
a complete and accurate disclosure of the nature and scope of any consumer report the Company ordered about you. The consumer
reporting agency must provide you with this disclosure within 5 days after (i) its receipt of your request or (ii) the date the report was
requested by the Company, whichever date is later.
NEW JERSEY: You have the right to submit a request to the consumer reporting agency (e.g., HireRight) for a copy of any investigative
consumer report the Company requested about you.
NEW YORK: You have the right, upon written request to the Company, to be informed of whether or not the Company requested a
consumer report or an investigative consumer report about you. Shown above is the address and telephone number for HireRight, the
consumer reporting agency used by the Company. You may inspect and receive a copy of any such report by contacting that consumer
reporting agency. A copy of Article 23-A of the New York Correction Law is also provided below.
WASHINGTON STATE: If the Company requests an investigative consumer report, you have the right, upon written request made to the
Company within a reasonable period of time after your receipt of this disclosure, to receive from the Company a complete and accurate
disclosure of the nature and scope of the investigation requested by the Company. You are entitled to this disclosure within 5 days after
the date your request is received or the Company ordered the report, whichever is later. You also have the right to request a written
summary of your rights and remedies under the Washington Fair Credit Reporting Act.
Request/Consent for Information from Previous Employer(s)/Carrier(s) For Alcohol and Controlled Substances Testing
Records
And changes in Parts 390 and 391 of the FMCSA
Terry Walker
X X
2383 Noble Rd
Date Social Security Number
2610 Idlewood
Cleveland Hts, OH 44118
Gender:
Terry Walker
X X
Print Name (First, MI, Last) Signature
I, the above mentioned signer, hereby authorize JRL.King transportaion
To release and forward in accordance with the following regulation, all known information pertaining to my alcohol and controlled substances
testing/training records to Pace Drivers
DISCLOSURE AND RELEASE
In accordance with DOT Regulation 49 CFR Part 391.23, I authorize the release of information from my DOT regulated drug and
alcohol testing records by the carriers (company/school) listed above to Pace Drivers, or to HireRight for the sole purpose of
transmitting such records to Pace Drivers. I authorize release of the following information concerning DOT drug and alcohol testing
violations including pre-employment tests during the past three years: (i) alcohol tests with a result of 0.04 or higher; (ii) verified
positive drug tests; (iii) refusals to be tested (including verified adulterated or substituted results); (iv) other violations of DOT drug and
alcohol testing regulations; (v) information obtained from previous employers of a drug and alcohol rule violation(s); and (vi)
documents, if any, of completion of a return-to-duty process following a rule violation. I also authorize the carriers (company/school)
listed above to release information about names and dates of previous employers, reasons for termination of employment, work
experience, accidents, academic history, professional credentials and other information.
The information that I have authorized Pace Drivers or HireRight to review involves tests required by DOT. If any carrier
(company/school) listed above furnishes Pace Drivers or HireRight with information concerning items (i) through (vi) above, I also
authorize that carrier (company/school) to release and furnish the dates of my negative drug and/or alcohol tests and/or tests with
results below 0.04 during the three-year period and the name and phone number of any substance abuse professional who evaluated
me during the past three years.
Request/Consent for Information from Previous Employer(s)/Carrier(s) For Alcohol and Controlled Substances Testing
Records
And changes in Parts 390 and 391 of the FMCSA
Terry Walker
X X
2383 Noble Rd
Date Social Security Number
2610 Idlewood
Cleveland Hts, OH 44118
Gender:
Terry Walker
X X
Print Name (First, MI, Last) Signature
I, the above mentioned signer, hereby authorize JRL.King transportion
To release and forward in accordance with the following regulation, all known information pertaining to my alcohol and controlled substances
testing/training records to Pace Drivers
DISCLOSURE AND RELEASE
In accordance with DOT Regulation 49 CFR Part 391.23, I authorize the release of information from my DOT regulated drug and
alcohol testing records by the carriers (company/school) listed above to Pace Drivers, or to HireRight for the sole purpose of
transmitting such records to Pace Drivers. I authorize release of the following information concerning DOT drug and alcohol testing
violations including pre-employment tests during the past three years: (i) alcohol tests with a result of 0.04 or higher; (ii) verified
positive drug tests; (iii) refusals to be tested (including verified adulterated or substituted results); (iv) other violations of DOT drug and
alcohol testing regulations; (v) information obtained from previous employers of a drug and alcohol rule violation(s); and (vi)
documents, if any, of completion of a return-to-duty process following a rule violation. I also authorize the carriers (company/school)
listed above to release information about names and dates of previous employers, reasons for termination of employment, work
experience, accidents, academic history, professional credentials and other information.
The information that I have authorized Pace Drivers or HireRight to review involves tests required by DOT. If any carrier
(company/school) listed above furnishes Pace Drivers or HireRight with information concerning items (i) through (vi) above, I also
authorize that carrier (company/school) to release and furnish the dates of my negative drug and/or alcohol tests and/or tests with
results below 0.04 during the three-year period and the name and phone number of any substance abuse professional who evaluated
me during the past three years.