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Information Safety

Location:
Tacoma, Washington, United States
Posted:
October 19, 2016

Contact this candidate

Name Scott Bandeen

Current Address Po Box ***

City, State/Province Zip/Postal Cocolalla, ID 83813 Country United States

SSN/SIN 3571

Date of Birth

Primary Phone 701-***-****

Cell Phone 701-***-****

Preferred method of contact Primary Phone

Best time to contact you Any

Email acw5cf@r.postjobfree.com

GENERAL INFORMATION

Position applying for: Driver

Do you have any relatives who worked for

this company?

No

Enter names and positions:

Do you have a current TWIC card? No

Expiration date:

How did you hear about us? Recruitment

DRIVING EXPERIENCE

For each class of equipment, enter type of equipment (van, tank, flat, etc.), start and end dates, and approximate number of total miles. If no experience in a class, enter

"NONE".

Straight Truck Pickup with 40'gooseneck trailer.

6/13 to 1/16

Tractor and Trailer Daycab w/ 53' flatbed

Tractor and Two Trailers

Other

List states operated in for the last 5 years: North Dakota Number of years of commercial driving

experience:

4

List any additional training you have had

that will help you as a commercial truck

driver:

DTS truck driving school

List any safety and/or safe driving awards

you have earned and from whom:

EDUCATION

List highest grade completed: College - 2

List last school attended (name, city, and

state):

Mesa community college

PERSONAL REFERENCES

List name, address, city, state, phone number, and relationship: First Reference: George Thornbill

208-***-****

Rathdrum,Idaho

Second Reference: Andre Deluge

208-***-****

Dufort road

Sagle,Idaho

Third Reference: Rob McCarthy

208-***-****

1003 Best Ave

Coeur d'Alene, Idaho

Licenses

License Number 60J

State/Province ID

Country United States

License Class Class A

License Expiration Date 08-22-2016

Physical Expiration Date 09-22-2016

Current License Yes

Commercial Driver License Yes

Endorsements

Tanker Endorsement Yes

HAZMAT Endorsement No

X Endorsement No

Doubles Triples Endorsement Yes

Other Endorsement No

Employment / Unemployment

Unemployment

Start Date 06-2016

End Date 09-2016

Comment

Unemployment

Start Date 01-2016

End Date 05-2016

Comment

Petroleum Services

PLEASE DO NOT CONTACT

Company Petroleum Services

Contact / Supervisor Name

Start Date 02-2013

End Date 12-2015

Address 4th ave.

City, State/Province Zip/Postal Williston, ND 58801 Country United States

Phone

Position Held

Reason for leaving? Oil pricex

Were you terminated/discharged/laid off? Yes

Termination Explanation Mutual agreement

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

Areas Driven N.&S. Dakota's

Miles driven weekly

Pay Range (cents/mile)

Most common truck driven Other

Most common trailer Flatbed

Trailer length 32 to 44 feet

Unemployment

Start Date 05-2006

End Date 08-2012

Comment

Trucking School

Start Date 09-2012

End Date 01-2013

School DTS

City, State/Province Medical Lake,washington, WA

Country United States

Phone

Did you graduate? Yes

Yes

Were you subject to the Federal Motor

Carrier or Transport Canada Safety

Regulations while attending this truck

school?

Did you perform any safety sensitive

functions at this truck school, regulated by

DOT, and subject to drug and alcohol

testing?

Yes

GPA 4.0

Hours of Instruction 60

Border Crossing No

Log Books Yes

Federal Motor Carrier Regulations Yes

Hazardous Materials No

Motor Vehicle Record

1. Has any license, permit or privilege ever

been denied, suspended or revoked for

any reason?

No

2. Have you ever been convicted of driving

during license suspension or revocation, or

driving without a valid license or an expired

license, or are any charges pending?

No

3. Have you ever been convicted for any

alcohol or controlled substance related

offense while operating a motor vehicle, or

are any charges pending?

No

4. Have you ever been convicted for

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?

No

5. Have you ever been convicted of

reckless driving, careless driving or

careless operation of a motor vehicle, or

are any charges pending?

No

6. Have you ever tested positive, or

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

No

on any DOT-mandated drug or alcohol

test?

Vehicle Accident Record

Were you involved in any accidents/incidents with any vehicle in the last 3 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

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

PSP Release

I agree with the above language Yes

User Requested Copy

User requested a copy to be sent to this

email address acw5cf@r.postjobfree.com.

Yes

By my check of this box, I represent that I

understand and agree to the above and

that I intend to execute this document by

electronic signature in checking this box.

Yes

Signature

Full Name Scott Bandeen

IP Address 97.45.144.251

Signature Date/Time 09-19-2016 11:16 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: 09-19-2016 11:16 PM

Signed:

CONSUMER REPORT DISCLOSURE AND RELEASE

In connection with your employment or application for employment (including contract for services) with Sherman Brothers Trucking, 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:

Scott Bandeen

Social Security #:

3571

Signed Date: 09-19-2016

Scott Bandeen

Po Box 581

Cocolalla, ID 83813

701-***-****

Gender:

IMPORTANT DISCLOSURE

REGARDING BACKGROUND REPORTS ("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 Sherman Brothers Trucking ("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:

Scott Bandeen

Signed Date: 09-19-2016

TO BE READ AND SIGNED BY APPLICANT

If I am selected as an employee or independent contractor for the Company I understand and authorize that a periodic investigation may be requested for the duration of my association with the Company. I understand that this release and authorizations shall remain in effect for the duration of my association with the Comapny. Additionally, I hereby authorize the Company to investigate any incidents of workplace misconduct made against or involving me both during and after the term of my association with the Company. I understand and agree that any information provided by me that is found to be false, incomplete or misrepresented in any respect in the Company's sole judgement, will be cause to cancel further consideration of my application for employment and/or contracting services whenever such discrepancies are discovered. Further, I understand that by requesting this information that no promise of employment is being made. I am willing that a photocopy of this authorization will be accepted with the same authority as the original. I HEREBY CERTIFY THAT THIS FORM WAS COMPLETED BY ME, AND THAT THE INFORMATION PROVIDED IS TRUE AND CORRECT AS OF THE DATE HEREOF.

Printed Name: Scott Bandeen

Social Security #: 3571

Signed Date: 09-19-2016

Signed:

PRE-EMPLOYMENT AGREEMENT

I consent to the testing of specimens provided by me in order to determine the presence of controlled substances and I recognize that the analysis results of such specimens will be used to determine suitability of employment. I understand that favorable test results will not necessarily guarantee that I will be offered employment at SBI. At this time I consent to a drug and/or alcohol test.

Printed Name: Scott Bandeen

Social Security #: 3571

Signed Date: 09-19-2016

Signed:

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 09-19-2016

Date

X 3571

Social Security Number

Scott Bandeen

Po Box 581

Cocolalla, ID 83813

701-***-****

Gender:

X Scott Bandeen

Print Name (First, MI, Last)

X

Signature

I, the above mentioned signer, hereby authorize Petroleum Services To release and forward in accordance with the following regulation, all known information pertaining to my alcohol and controlled substances testing/training records to Sherman Brothers Trucking DOT DRUG AND ALCOHOL RELEASE

I authorize, per 49 CFR Part 40, the release of information from my DOT regulated drug and alcohol testing records by the carriers (company/school) listed to USIS for the sole purpose of transmitting such records to Sherman Brothers Trucking, or directly to Sherman Brothers Trucking. 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. The information that I have authorized USIS to review involves tests required by DOT. If any carrier (company/school) listed above furnishes USIS 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. CONSUMER REPORT DISCLOSURE AND RELEASE

In connection with your employment or application for employment (including contract for services) with Sherman Brothers Trucking, 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. Employer / Contractor / Educational Institution:

DTS

Printed Name:

Scott Bandeen

Social Security #:

3571

Signed Date: 09-19-2016

Scott Bandeen

Po Box 581

Cocolalla, ID 83813

701-***-****

Gender:



Contact this candidate