Information Driver
Resume:
Averitt Express, Inc. (ND)
Cookeville, TN 38502
**-**-**** **:51:18AM CDT
IntelliApp (ND)
To apply with Averitt Express, please click here to go to the main application page. We believe in the principles of equal employment opportunity and fully intend to fulfill our obligations. No person seeking employment with Averitt shall be subject to adverse treatment on the basis of race, color, religion, age, sex, national origin, disability, veteran status, or any other status protected by law.
If you need reasonable accommodation to complete the online application, please contact the Human Resources Department.
Position City State/Province
Dock Worker Part Time Houston TX
Personal Information
Referral Code: Group1201_med001_Dock-Worker-Part-Time_Houston Name Hyrom Wicks Ellis
Residence 3 years or longer (If No,
previous addresses shown below)
Yes
Current Address 6102 Willow Glen Drive
City, State/Province Zip/Postal 77033, TX 77033
Country United States
SSN/SIN 9078
Date of Birth
Primary Phone 832-***-****
Cell Phone 832-***-****
Preferred method of contact Primary Phone
Best time to contact you Any
Email ac22tl@r.postjobfree.com
1
Prescreen Detail
I understand if I receive a
conditional offer of
employment, I will be required
to submit to a urine and/or hair
follicle drug test?
Yes
Have you been convicted of a
DUI/DWI within the past 5
years?
No 10
Have you been convicted of
reckless driving within the past
5 years?
No 10
Have you been convicted of
more than 2 moving violations
within the past 3 years?
No 10
Has your license been denied
within the past 5 years as a
result of a traffic conviction?
No 10
Has your license been
suspended within the past 5
years as a result of a traffic
conviction?
No 10
Has your license been
revoked within the past 5
years as a result of a traffic
conviction?
No 10
Do you have a valid driver's
license?
Yes 10
Are you at least 18 years of
age?
Yes 10
Company Questions
PERSONAL INFORMATION
How did you hear about us? INTERNET
If employee, enter employee's name: NONE
If other, please explain: NONE
Have you ever applied with this company
before?
Yes
Where and when? 6 MO A GO
Have you ever interviewed with this
company before?
No
2
Where and when?
Have you ever worked for this company
before?
No
Where and when?
If necessary, will you travel? No
Extent percentage?
If necessary, will you relocate? No
Where?
If necessary, will you work:
Saturdays? Yes
Sundays? Yes
Shift Work? Yes
Overtime? Yes
Shift Preferred: ANY
Are you 18 years of age or over? Yes
If you were in the military please list all
MOSs or AFSCs during your service
N/A
Are you still serving in National Guard or
Reserves?
No
Are there any other names you have used
in the past of which we should be aware in
order to verify any information provided?
No
Please list:
Please list two (2) professional and/or academic references that may be contacted. Do not list relatives or previous employers. Include name, complete address, occupation, and phone number.
First Reference: NONE
Second Reference: NONE
EDUCATION
Do you have your high school
diploma/GED?
Yes
NONE
3
List any training program presently
attending. Include school name, city, state,
phone number, start date, and
certifications
Licenses
License Number 884
State/Province TX
Country United States
License Class Class A
License Expiration Date 08-01-2018
Physical Expiration Date 08-01-2018
Current License Yes
Commercial Driver License Yes
Endorsements
Tanker Endorsement Yes
HAZMAT Endorsement Yes
Hazmat Expiration Date 11-16-2017
X Endorsement Yes
Doubles Triples Endorsement No
Other Endorsement No
Employment / Unemployment
Unemployment
Start Date 06-2017
End Date 06-2017
Comment NONE
Self Employed
PLEASE DO NOT CONTACT
Company Self Employed
Contact / Supervisor Name
Start Date 05-2017
End Date 05-2017
Address 6102 WILLOW GLEN DRIVE
City, State/Province Zip/Postal Houston, TX 77033
4
Country United States
Phone 832-***-****
Position Held WORK BY TRADE
Brief Job Description (e.g., "OTR driver in
southeast US", "loaded and unloaded
trucks at distribution center")
Reason for leaving? NONE
Were you terminated/discharged/laid off? No
Is this your current employer? No
May we contact this employer at this time? No
Did you operate a commercial motor
vehicle?
No
Were you subject to the Federal Motor
Carrier or Transport Canada Safety
Regulations while employed/contracted by
this employer/contractor?
Did you perform any safety sensitive
functions in this job subject to drug and
alcohol testing?
Pay Range (cents/mile)
Most common truck driven
Most common trailer
Trailer length
Unemployment
Start Date 09-2016
End Date 04-2017
Comment SELF EMPLOYED
Unemployment
Start Date 09-2016
End Date 04-2017
Comment Self-employed
Southern Refrigerated Transportation
PLEASE DO NOT CONTACT
Company Southern Refrigerated Transportation
Contact / Supervisor Name
Start Date 03-2014
End Date 08-2016
5
Address PO Box 459
City, State/Province Zip/Postal Texarkana, AR 71822 Country United States
Phone 870-***-****
Fax 870-***-****
Position Held DRIVER
Brief Job Description (e.g., "OTR driver in
southeast US", "loaded and unloaded
trucks at distribution center")
DELIVERY
Reason for leaving? FAMILY PROBLMES
Were you terminated/discharged/laid off? No
Is this your current employer? No
May we contact this employer at this time? No
Did you operate a commercial motor
vehicle?
Yes
Were you subject to the Federal Motor
Carrier or Transport Canada Safety
Regulations while employed/contracted by
this employer/contractor?
Yes
Did you perform any safety sensitive
functions in this job, regulated by DOT,
and subject to drug and alcohol testing?
Yes
Pay Range (cents/mile) .38
Most common truck driven Sleeper Tractor-Cabover /Conventional Most common trailer Reefer Unit
Trailer length 45 feet or longer
Unemployment
Start Date 02-2010
End Date 02-2014
Comment
AGL.Elite Business Solutions
Company AGL.Elite Business Solutions
Contact / Supervisor Name
Start Date 10-2009
End Date 01-2010
Address 2403Fannin Street
City, State/Province Zip/Postal Houston, TX 77002
6
Country United States
Phone 713-***-****
Position Held Tempary Driver
Brief Job Description (e.g., "OTR driver in
southeast US", "loaded and unloaded
trucks at distribution center")
Reason for leaving? It was a tempary Company
Were you terminated/discharged/laid off? No
Did you operate a commercial motor
vehicle?
No
Were you subject to the Federal Motor
Carrier or Transport Canada Safety
Regulations while employed/contracted by
this employer/contractor?
Did you perform any safety sensitive
functions in this job, regulated by DOT,
and subject to drug and alcohol testing?
Pay Range (cents/mile)
Most common truck driven
Most common trailer
Trailer length
Empire Truck Lines Inc.
Company Empire Truck Lines Inc.
Contact / Supervisor Name
Start Date 10-2008
End Date 10-2009
Address 10043Wallisville Road
City, State/Province Zip/Postal Houston, TX 77013
Country United States
Phone 713-***-****
Fax 713-***-****
Position Held Regional Truck Driver
Brief Job Description (e.g., "OTR driver in
southeast US", "loaded and unloaded
trucks at distribution center")
Reason for leaving? I Quit For A Better Opprtunity With Schneider
Were you terminated/discharged/laid off? No
7
Did you operate a commercial motor
vehicle?
Yes
Were you subject to the Federal Motor
Carrier or Transport Canada Safety
Regulations while employed/contracted by
this employer/contractor?
Yes
Did you perform any safety sensitive
functions in this job, regulated by DOT,
and subject to drug and alcohol testing?
Yes
Pay Range (cents/mile)
Most common truck driven Day Cab
Most common trailer Dry Van
Trailer length 53 feet or more
J.B.Hunt Transport
Company J.B.Hunt Transport
Contact / Supervisor Name
Start Date 08-2008
End Date 09-2008
Address 350 Gellhorn Drive
City, State/Province Zip/Postal Houston, TX 77013
Country United States
Phone 800-***-****
Position Held Over The Road Driver
Brief Job Description (e.g., "OTR driver in
southeast US", "loaded and unloaded
trucks at distribution center")
Reason for leaving? I Haed Familie Problem
Were you terminated/discharged/laid off? No
Did you operate a commercial motor
vehicle?
Yes
Were you subject to the Federal Motor
Carrier or Transport Canada Safety
Regulations while employed/contracted by
this employer/contractor?
Yes
Did you perform any safety sensitive
functions in this job, regulated by DOT,
and subject to drug and alcohol testing?
Yes
Pay Range (cents/mile)
Most common truck driven Day Cab Conventiona
8
Most common trailer Dry Van
Trailer length 53 feet or more
Express Employment Professionals
Company Express Employment Professionals
Contact / Supervisor Name
Start Date 06-2008
End Date 07-2008
Address 2401Fountainview Drive
City, State/Province Zip/Postal Houston, TX 77057
Country United States
Phone 713-***-****
Fax 512-***-****
Position Held Fork Lift Operaor
Brief Job Description (e.g., "OTR driver in
southeast US", "loaded and unloaded
trucks at distribution center")
Reason for leaving? It was a tempary position
Were you terminated/discharged/laid off? No
Did you operate a commercial motor
vehicle?
No
Were you subject to the Federal Motor
Carrier or Transport Canada Safety
Regulations while employed/contracted by
this employer/contractor?
Did you perform any safety sensitive
functions in this job, regulated by DOT,
and subject to drug and alcohol testing?
Pay Range (cents/mile)
Most common truck driven
Most common trailer
Trailer length
Unemployment
Start Date 11-2007
End Date 05-2008
Comment Self-employed
Empire Truck Lines Inc.
Company Empire Truck Lines Inc.
9
Contact / Supervisor Name
Start Date 10-2006
End Date 10-2007
Address 10043Wallisville Road
City, State/Province Zip/Postal Houston, TX 77013
Country United States
Phone 713-***-****
Fax 713-***-****
Position Held Regional Truck Diver
Brief Job Description (e.g., "OTR driver in
southeast US", "loaded and unloaded
trucks at distribution center")
Reason for leaving? I Whint In To The HOSPITAL
Were you terminated/discharged/laid off? No
Did you operate a commercial motor
vehicle?
Yes
Were you subject to the Federal Motor
Carrier or Transport Canada Safety
Regulations while employed/contracted by
this employer/contractor?
Yes
Did you perform any safety sensitive
functions in this job, regulated by DOT,
and subject to drug and alcohol testing?
Yes
Pay Range (cents/mile)
Most common truck driven Day Cab
Most common trailer Other
Trailer length 53 feet or more
Schneider National
Company Schneider National
Contact / Supervisor Name
Start Date 06-2005
End Date 10-2006
Address 34500L.B.J Freeway
City, State/Province Zip/Postal Green Bay, WI 54313 Country United States
Phone 800-***-****
Fax 215-***-****
10
Position Held Over The Road Driver
Brief Job Description (e.g., "OTR driver in
southeast US", "loaded and unloaded
trucks at distribution center")
Reason for leaving? I Was Need At Home A Familie Problem Were you terminated/discharged/laid off? No
Did you operate a commercial motor
vehicle?
Yes
Were you subject to the Federal Motor
Carrier or Transport Canada Safety
Regulations while employed/contracted by
this employer/contractor?
Yes
Did you perform any safety sensitive
functions in this job, regulated by DOT,
and subject to drug and alcohol testing?
Yes
Pay Range (cents/mile)
Most common truck driven Conventional Tractor
Most common trailer Dry Van
Trailer length 53 feet or more
Transport Leasing
Company Transport Leasing
Contact / Supervisor Name
Start Date 04-2001
End Date 04-2002
Address 325 Soth Calumet
City, State/Province Zip/Postal Daytion, TX 46304
Country United States
Phone 219-***-****
Fax 219-***-****
Position Held Regional Truck Driver
Brief Job Description (e.g., "OTR driver in
southeast US", "loaded and unloaded
trucks at distribution center")
Reason for leaving? Quit for a better oprtunity
Were you terminated/discharged/laid off? No
Did you operate a commercial motor
vehicle?
Yes
Were you subject to the Federal Motor
Carrier or Transport Canada Safety
Yes
11
Regulations while employed/contracted by
this employer/contractor?
Did you perform any safety sensitive
functions in this job, regulated by DOT,
and subject to drug and alcohol testing?
Yes
Pay Range (cents/mile)
Most common truck driven Tanker
Most common trailer Tanker
Trailer length 45 to 52 feet
Five Star Transportation
Company Five Star Transportation
Contact / Supervisor Name
Start Date 04-2000
End Date 04-2001
Address P.O.Box9670
City, State/Province Zip/Postal Houston, TX 77213
Country United States
Phone 281-***-****
Position Held Regional Truck Driver
Brief Job Description (e.g., "OTR driver in
southeast US", "loaded and unloaded
trucks at distribution center")
Reason for leaving? Company Wint Out Of Business
Were you terminated/discharged/laid off? No
Did you operate a commercial motor
vehicle?
Yes
Were you subject to the Federal Motor
Carrier or Transport Canada Safety
Regulations while employed/contracted by
this employer/contractor?
Yes
Did you perform any safety sensitive
functions in this job, regulated by DOT,
and subject to drug and alcohol testing?
Yes
Pay Range (cents/mile)
Most common truck driven Conventional Tractor
Most common trailer Flatbed
Trailer length 45 to 52 feet
Rapid Freight Of Texas
12
Company Rapid Freight Of Texas
Contact / Supervisor Name
Start Date 05-1999
End Date 04-2000
Address 1912West Pecan
City, State/Province Zip/Postal Pflugerville, TX 78660 Country United States
Phone 512-***-****
Position Held Over The Road Driver
Brief Job Description (e.g., "OTR driver in
southeast US", "loaded and unloaded
trucks at distribution center")
Reason for leaving? CompanyWint Out Of Business
Were you terminated/discharged/laid off? No
Did you operate a commercial motor
vehicle?
Yes
Were you subject to the Federal Motor
Carrier or Transport Canada Safety
Regulations while employed/contracted by
this employer/contractor?
Yes
Did you perform any safety sensitive
functions in this job, regulated by DOT,
and subject to drug and alcohol testing?
Yes
Pay Range (cents/mile)
Most common truck driven Conventional Tractor
Most common trailer Dry Van
Trailer length 53 feet or more
E.C.K.Miller
Company E.C.K.Miller
Contact / Supervisor Name
Start Date 09-1997
End Date 10-1998
Address 1011Ulrich Ave
City, State/Province Zip/Postal Louisville, KY 40219 Country United States
Phone 502-***-****
Position Held Over The Road Driver
13
Brief Job Description (e.g., "OTR driver in
southeast US", "loaded and unloaded
trucks at distribution center")
Reason for leaving? Familie Problem
Were you terminated/discharged/laid off? No
Did you operate a commercial motor
vehicle?
Yes
Were you subject to the Federal Motor
Carrier or Transport Canada Safety
Regulations while employed/contracted by
this employer/contractor?
Yes
Did you perform any safety sensitive
functions in this job, regulated by DOT,
and subject to drug and alcohol testing?
Yes
Pay Range (cents/mile)
Most common truck driven Conventional Tractor
Most common trailer Other
Trailer length 45 to 52 feet
Vehicle Accident Record
This section asks about accidents and incidents. Please complete this section for ANY accidents or incidents in a commercial OR personal vehicle, DOT Recordable OR Non-recordable regardless of fault including but not limited to:
• Backing
• Turning
• Striking a fixed object (power lines, posts, fences etc)
• Miscellaneous Property Damage (curbs, landscaping etc)
• Dropped Trailer
• Rollover / Roll Away
• Rear End Collision
• Loss of Vehicle Control
• Leaving the Roadway
• Tow Away Incident
• Striking Road Debris
• Found Damage
Failure to list an accident/incident may disqualify you. Were you involved in any accidents/incidents with any vehicle in the last 5 years (even if not at fault)?
No Accidents
14
Traffic Convictions \ Violations
This section asks about moving violations. Please complete this section if you have been convicted of ANY moving violations including but not limited to:
• Failure to yield
• Failure to obey traffic control/sign/device
• Speeding
• Improper Lane Use/Lane Change
• Improper Passing/
Failure to list a moving violation may disqualify you. Have you had any moving violations or traffic convictions in the past 5 years? No Violations
Criminal Record
Have you EVER been convicted of a
felony, pled guilty or "nolo contendere" to a
felony, or had the adjudication of guilt
withheld for a crime that is a felony?
No
If "Yes", enter month, year, and a brief
description:
Have you been placed on probation, fined,
or given a suspended sentence for
committing a felony?
No
If "Yes", enter month, year, and a brief
description:
Have you been convicted of a
misdemeanor involving theft, violence or
sexually related crime within the past 10
years, plead guilty or "nolo contendere" to
a misdemeanor involving theft, violence, or
sexually related crime OR had the
adjudication of guilt withheld for a crime
that is a misdemeanor involving theft,
violence or sexually related crime?
No
If "Yes", enter month, year, and a brief
description:
Within the last 5 years have you ever been
convicted of a misdemeanor involving
drugs, plead guilty or "NOLO
CONTENDERE" to a misdemeanor
involving drugs, or had the adjudication of
guilt withheld for a crime that is a
misdemeanor involving drugs?
No
If "Yes", enter month, year, and a brief
description:
15
Are you currently involved in any pending
court action that could result in a felony
conviction or misdemeanor conviction
involving theft, violence, sexual, or drug
related offenses that would disqualify you
from employment?
No
If "Yes", enter month, year, and name of
employer for the drug test you FAILED.
For the previous employer(s) listed, I have
FAILED a DOT Alcohol and/or Drug Test
for a Safety-Sensitive transportation
position within the past three (3) years?
No
If "Yes", enter month, year, and name of
employer for the drug test you FAILED:
For the previous employer(s) listed, I have
REFUSED to be tested on a DOT Alcohol
and/or Drug Test for a Safety-Sensitive
transportation position within the past three
(3) years
No
If "Yes", enter month, year, name of
employer for the drug test you REFUSED:
Federal FCRA Summary of Rights Acknowledgment
By checking this box, I acknowledge that I
have read and understand the Summary of
Rights.
Yes
Drug and Alcohol Release
I agree with the above language Yes
Certification Release
I agree with the above language Yes
User Requested Copy
User requested a copy to be sent to this
email address
ac22tl@r.postjobfree.com.
Yes
By my check of this box, I represent that I
understand and agree to the above and
Yes
16
that I intend to execute this document by
electronic signature in checking this box.
Signature
Full Name Hyrom Wicks Ellis
IP Address 76.31.166.42
Signature Date/Time 06-21-2017 10:51 AM
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: 06-21-2017 10:51 AM
Signed:
17
USIS Customer #
CONSUMER REPORT DISCLOSURE AND RELEASE
In connection with your employment or application for employment (including contract for services) with Averitt Express, Inc., consumer reports may be requested from USIS Commercial Services (USIS). These reports may include the following types of information: names and dates of previous employers, reason for termination of employment, work experience, accidents, academic history, professional credentials, and drugs/alcohol use. Such reports may contain public record information concerning your driving record, workers compensation claims, credit, bankruptcy proceedings, criminal records, etc., from federal, state and other agencies which maintain such records; as well as information from USIS concerning previous driving record requests made by others from such state agencies and state provided driving records. You have the right to make a request to USIS, upon proper identification, to request the nature and substance of all information in its files on you at the time of your request, including the sources of information and the recipients of any reports on you that USIS has previously furnished within the three-year period preceding your request. USIS may be contacted by mail at P.O. Box 33181, Tulsa, Oklahoma, 74153, or by phone at 800-***-****.
I AUTHORIZE, WITHOUT RESERVATION, USIS, AND ANY PARTY OR AGENCY CONTACTED BY USIS, TO FURNISH THE ABOVE-MENTIONED INFORMATION. THIS AUTHORIZATION DOES NOT APPLY TO DRUG AND ALCOHOL INFORMATION OBTAINED UNDER PART I. I hereby consent to your obtaining the above information from USIS, and I agree that such information which USIS has or obtains, and my employment history (not DOT Drug and Alcohol information without a specific consent by me) with you if I am hired, will be supplied by USIS to other companies which subscribe to USIS. I hereby authorize procurement of consumer report(s). If hired or contracted, this authorization, for reports covered by this release only, shall remain on file and shall serve as ongoing authorization for you to procure consumer reports at any time during my employment or contract period.
Notice to California Applicants
Under California law, the consumer reports we order on you for employment purposes within the State of California are defined as investigative consumer reports. These reports may contain information on your character, general reputation, personal characteristics and mode of living. Under section 1786.22 of the California Civil Code, you may view the file maintained on you by USIS during normal business hours. You may also obtain a copy of this file upon submitting proper identification and paying the costs of duplication services, by appearing at USIS in person or by mail. The agency is required to have personnel available to explain your file to you and the agency must explain to you any coded information appearing in your file. If you appear in person, a person of your choice may accompany you, provided that this person furnishes proper identification. Printed Name:
Hyrom Wicks Ellis
Social Security #:
9078
Signed Date: 06-21-2017
Hyrom Wicks Ellis
6102 Willow Glen Drive
77033, TX 77033
Gender:
18
PLEASE READ AND SIGN BELOW
I understand that the accuracy and completeness of the information provided in my application for employment with Averitt associated with the Release Form, any supplemental forms, or pre-employment interviews is relied upon by Averitt in making an employment decision. I understand that it is my responsibility to notify Averitt of any change in the information provided during the employment process. I understand that any misrepresentation, misstatement, omission or other attempt to mislead, at any stage of the employment process, is grounds for refusal to hire or, if already hired at the time of discovery, my dismissal. I understand that, if I am selected for possible employment, a criminal background check may be conducted to verify the information I have provided. I also understand that any prior employer or reference may be contacted either before or after a conditional offer is extended. I hereby authorize and request any former employer, or any other persons or companies, including any city, county, state or federal agency, department or bureau, to furnish to Averitt Express, Inc., or its authorized representatives, any information in their files under my name. I also hereby authorize any motor carrier to investigate my background, prior work history, including any and all results from drug and alcohol testing (screening) in accordance with regulations of the Federal Highway Administration (FHWA), title 49, sections 382.405, 382.413, 383.35, 391.23 and 391.27. I agree to hold any source of information harmless for any error in reporting this information and release all such persons from any damages on account of furnishing said information. A photocopy of this authorization may be accepted by anyone as though it were the original. I understand that, following a preliminary decision to hire, I will be asked to submit to a medical examination and/or a drug and alcohol screen. I understand that any offer of employment will be conditioned upon the results of the examination and/or screen. If employed, I agree to conform to the rules and regulations of the company and acknowledge that their rules and regulations may be changed, interpreted, withdrawn, or added to by the company at any time, at the company's sole option and without any prior notice to me. I further acknowledge that my employment may be terminated, and any offer of employment, or my acceptance of an employment offer, if such is to occur, may be withdrawn at any time, with or without cause, at the option of the company or myself. I understand that all employment is "at will" and that no representative of the company has authority to enter into any agreement for employment for any specified period of time or to assure any other personnel action, either prior to commencement of employment or after I have become employed, or to assure any benefits or terms and conditions of employment, or make any agreement contrary to the foregoing. I acknowledge that I have been advised that my employment application associated with this Release Form will remain active for no more than 90 days from the date it was made.
Printed Name: Hyrom Wicks Ellis
Social Security #: 9078
Signed Date: 06-21-2017
Signed:
19
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
X 06-21-2017
Date
X 9078
Social Security Number
Hyrom Wicks Ellis
6102 Willow Glen Drive
77033, TX 77033
Gender:
X Hyrom Wicks Ellis
Print Name (First, MI, Last)
X
Signature
I, the above mentioned signer, hereby authorize Southern Refrigerated Transportation To release and forward in accordance with the following regulation, all known information pertaining to my alcohol and controlled substances testing/training records to Averitt Express, Inc. (ND) DOT DRUG AND ALCOHOL RELEASE
I authorize, per 49 CPR Part 40, the release of information from my DOT regulated drug and alcohol testing records by the carriers (company/school) listed below for the sole purpose of transmitting such records to Averitt Express, Inc. I authorize release of the following information concerning DOT drug and alcohol testing violations 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.
The information that I have authorized involves tests required by DOT. If any carrier (company/school) listed below furnishes 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 two years.
20
USIS Customer #
CONSUMER REPORT DISCLOSURE AND RELEASE
In connection with your employment or application for employment (including contract for services) with Averitt Express, Inc., consumer reports may be requested from USIS Commercial Services (USIS). These reports may include the following types of information: names and dates of previous employers, reason for termination of employment, work experience, accidents, academic history, professional credentials, and drugs/alcohol use. Such reports may contain public record information concerning your driving record, workers compensation claims, credit, bankruptcy proceedings, criminal records, etc., from federal, state and other agencies which maintain such records; as well as information from USIS concerning previous driving record requests made by others from such state agencies and state provided driving records. You have the right to make a request to USIS, upon proper identification, to request the nature and substance of all information in its files on you at the time of your request, including the sources of information and the recipients of any reports on you that USIS has previously furnished within the three-year period preceding your request. USIS may be contacted by mail at P.O. Box 33181, Tulsa, Oklahoma, 74153, or by phone at 800-***-****.
I AUTHORIZE, WITHOUT RESERVATION, USIS, AND ANY PARTY OR AGENCY CONTACTED BY USIS, TO FURNISH THE ABOVE-MENTIONED INFORMATION. THIS AUTHORIZATION DOES NOT APPLY TO DRUG AND ALCOHOL INFORMATION OBTAINED UNDER PART I. I hereby consent to your obtaining the above information from USIS, and I agree that such information which USIS has or obtains, and my employment history (not DOT Drug and Alcohol information without a specific consent by me) with you if I am hired, will be supplied by USIS to other companies which subscribe to USIS. I hereby authorize procurement of consumer report
Contact this candidate