Information Safety
Resume:
TMC Transportation
Des Moines, IA 50321
**-**-**** **:26:47PM CST
IntelliApp
Position City State/Province
Class A OTR Flatbed Truck
Driver
Any City TX
Personal Information
Name Adam Wyane Rickenbacker
Current Address 1001 North Pine Dr
City, State/Province Zip/Postal Conroe, TX 77301
Country United States
SSN/SIN 8418
Date of Birth
Primary Phone 936-***-****
Preferred method of contact Cell Phone
Best time to contact you Any
Email ************@*****.***
Yes, I want to receive text messages from
TMC Transportation. *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.
Yes
Company Questions
Set WL from URL
Are you currently enrolled in a trucking
school?
No
Most recent trucking school attended?
Have you worked at TMC previously? No
Do you have 3 months of recent Class A
driving experience?
No
Are you currently looking for a truck driving
school?
Yes
1
Do you have a class A license? No
General Information
How did you find out about TMC? TMC Office/Shop Employee Specific name of publication / website /
event / employee
Tmc
Are you legally eligible to work in the
United States?
Yes
Have you ever been refused a security
bond?
No
Please explain:
Height (feet)** 5
Height (inches)** 11
Weight (pounds)** 190
In case of emergency, who should we notify? (please list name, relationship to you, full address and phone)
Contact Name: Debbie Brannon
Contact relationship to you: Mom
Contact street address: 1001 norrh pine dr
Contact City: Conroe
Contact State: TX
Contact Zip: 77301
Contact Phone (including area code): 936-***-****
Educational Background
Select highest grade completed: Grade 12
Name of last school attended: Conroe high school
Did you graduate? No
Truck and Trailer Info
Only complete this section if you are an owner operator. Are you an owner/operator? No
Please list the make, model and year of
your tractor:
Please list the make, model and year of
your trailer:
Physical History
Federal Motor Carrier Safety Regulations Section 391.41 provides that a person shall not drive a motor vehicle unless that person is physically qualified to do so. It is an essential function of an over-the-road driver to satisfy the DOT qualifications. Please answer Yes or No to the following questions.
2
Below is a list of questions that will be asked on the mandatory Department of Transportation Physical Examination form.
Have you ever received professional help for:
Heart:** No
If yes, date:**
If yes, please provide detail:**
Spinal injury/chronic low back pain:** No
If yes, date:**
If yes, please provide detail:**
Physical Disorders:** No
If yes, date:**
If yes, please provide detail:**
Seizures:** No
If yes, date:**
If yes, please provide detail:**
Sleep Disorders:** No
If yes, date:**
If yes, please provide detail:**
High Blood Pressure:** No
If yes, date:**
If yes, please provide detail:**
Cardiovascular Disease:** No
If yes, date:**
If yes, please provide detail:**
Diabetes:** No
If yes, date:**
If yes, please provide detail:**
Any other Nervous Disorders:** No
If yes, date:**
If yes, please provide detail:**
Vision - Do you have at least 20/40
(Snellen) with or without corrective lenses
in both eyes?
Yes
List all medications currently being taken:** None 3
Have you had any time lost from work in
the past years?
Yes
Time lost from work in the past three years
(select closest, in months):
1
Do you use, or have you ever used,
amphetamines, narcotics, marijuana, or
any other habit forming drug or controlled
substance?
No
Please explain.
Can you perform the following essential job functions with or without reasonable accomodation:
Pull 5th wheel pin with an average of 200
lbs force?
Yes
Tarp loads at heights of 13'6"? Yes
Pull yourself into a tractor at 60% of your
body weight?
Yes
Lift 80 pound tarps over your head? Yes
Licenses
Please enter all licenses held in the previous 3 years. License Number 133
State/Province TX
Country United States
License Class
License Expiration Date 05-30-2020
Physical Expiration Date
Current License Yes
Commercial Driver License No
Endorsements None
Employment / Unemployment
Able glass
Company Able glass
Start Date 01-2012
End Date 01-2017
Address N frazier
City, State/Province Zip/Postal Conroe, TX 77301
4
Country United States
Phone 936-***-****
Position Held Commercial installation
Reason for leaving? Money
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
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 All over houston
Miles driven weekly 1500-2000
Pay Range (cents/mile) 15.00 per hour
Most common truck driven Other
Most common trailer Flatbed
Trailer length 31 feet or less
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
No
5
pending?
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
on any DOT-mandated drug or alcohol
test?
No
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
Criminal Record
Have you ever been convicted of a crime? Yes
Date 2-2014
City, State/Province Conroe, TX
Comment Falsly acused to reclesness with child give u more detal over phone
Do you have any deferred prosecutions? No
Do you have criminal charges pending? No
Have you ever pled "guilty" to, been
convicted of, or pled "no contest" to a
felony?
Yes
Date 2-2014
City, State/Province Conroe, TX
Comment Same
6
If you have any felony convictions, do you
currently hold a minister's permit to enter
or exit Canada?
No
Have you, within the last five years, pled
"guilty" to, been convicted of, had
prosecution deferred in connection with, or
pled "no contest" to a misdemeanor?
No
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 ************@*****.***.
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 Adam Wyane Rickenbacker
IP Address 72.26.23.253
Signature Date/Time 01-10-2017 12:26 PM
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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: 01-10-2017 12:26 PM
Signed:
8
CONSUMER REPORT DISCLOSURE AND RELEASE
In connection with your employment or application for employment (including contract for services) with Annett Holdings, 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.
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. 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 Annett Holdings, Inc., or directly to Annett Holdings, Inc. 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 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. 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:
Adam Wyane Rickenbacker
Social Security #:
8418
Signed Date: 01-10-2017
Adam Wyane Rickenbacker
1001 North Pine Dr
Conroe, TX 77301
Gender:
9
IMPORTANT DISCLOSURE
REGARDING BACKGROUND REPORTS FROM THE PSP Online Service In connection with your application for employment with TMC Transportation ("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 TMC Transportation ("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:
Adam Wyane Rickenbacker
Signed Date: 01-10-2017
10
TO BE READ AND SIGNED BY APPLICANT
By completing and submitting this application, I:
Agree and understand that the completion of this application does not constitute authorization for the applicant to drive, nor does it obligate in any way Annett Holdings, Inc. (d/b/a TMC Transportation) to authorize the applicant to drive.
•
Authorize Annett Holdings, Inc., (employer/lessor) and its subsidiaries, affiliates or its agents to request information which may contain but is not limited to the following information: names and dates of previous employer/lessors; reason for termination of employment/lease; work experience; accidents; etc.
•
Authorize Annett Holdings, Inc., and its subsidiaries, affiliates or its agents to request Driver Information Records from Transportation Information Services, Inc., d/b/a/ DAC Services ('DAC') relating to your previous driver employment/lease including but not limited to, previous driver employment/lease history. Motor Vehicle Record requests, Alcohol and Drug Test results, Criminal History and Insurance Claim Reports. I further understand that such information will include information from various state agencies which maintain records concerning traffic offenses, accidents, etc. as well as other information on file with DAC.
•
Understand and agree if I sustain an injury or illness arising from my employment/lease at Annett Holdings, Inc., I agree that Annett Holdings, Inc. shall be entitled to receive full and complete reports and records governing any medical or related examination and I authroize any and all such doctors, medical examiners, and hospitals to give to Annett Holdings, Inc., full and complete reports and records covering such examinations, condition, care and treatment related to or resulting from the alleged illness or injury. I further understand that if I sustain any injury or illness arising from my employment/lease at Annett Holdings, Inc., any such proceeding, action, or investigation, shall be governed exclusively by and constructed in accordanse with the laws of the State of Iowa, to include the Worker's Compensation Act.
•
Understand and agree that I will be required to submit and pass a drug test and various other tests as required as a conditional offer of pre-employment/lease and thereafter in accordance with Annett Holdings, Inc., policies and procedures and federal regulations.
•
Understand that Annett Holdings, Inc., uses an electronic filing system that includes the imaging and storing of employment/lease applications. This eliminates the retention of all original paper applications.
•
Agree that providing false, misleading or incomplete statements in this application and/or supplemental documents in connection with employer's/lessor's evaluation of me as a candidate for employment/lease is grounds for immediate termination of my employment/lease, regardless of when such information is discovered.
•
I understand that in order to investigate my safety employment/lease history, per FMCSA regulations, Annett Holdings, Inc., must investigate the information I provided by contacting all previous DOT regulated employers/lessors under which I was employed/leased in a safety sensitive function within the previous three years from the date of this employment/lease application. Applicants have the following rights regarding the investigative information that will be provided to Annett Holdings, Inc., pursuant FMCSA Reg 391.23 (i)(1):
1. The right to review investigative information provided by previous DOT employers/lessors for the preceding three years by submitting a written request to Annett Holdings, Inc., within 30 days after being employed/leased or of being notified of denial of employment/lease. 2. The right to have errors in the information corrected by their previous employer/lessor and for that previous employer/lessor to resend the corrected information to Annett Holdings, Inc. Applicants must send the request for the correction to the previous employer/lessor that provided the records to Annett Holdings, Inc. 3. The right to have a rebuttal statement attached to the alleged erroneous information, if the previous employer/lessor and the applicant cannot agree on the accuracy of the information. Applicant must send the rebuttal to the previous employer/lessor with instructions to include the rebuttal in that applicant's safety performance history. I certify 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.
Annett Holdings, Inc's hiring/leasing criteria and application process may be changed at any time at Annett Holding, Inc.'s discretion without prior notice.
11
Printed Name: Adam Wyane Rickenbacker
Social Security #: 8418
Signed Date: 01-10-2017
Signed:
12
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 01-10-2017
Date
X 8418
Social Security Number
Adam Wyane Rickenbacker
1001 North Pine Dr
Conroe, TX 77301
Gender:
X Adam Wyane Rickenbacker
Print Name (First, MI, Last)
X
Signature
I, the above mentioned signer, hereby
authorize
Able glass
To release and forward in accordance with the following regulation, all known information pertaining to my alcohol and controlled substances testing/training records to TMC Transportation
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 Annett Holdings, Inc. (9135), or directly to Annett Holdings, Inc. 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 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. 13
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