Ryder Integrated Logistics, Inc.
DOT#******
Miami, FL 33178
**-**-**** *:47:01PM CDT
IntelliApp
Personal Information
Name Kerry Baines
Current Address ***** ********* ***nt Ln
City, State/Province Zip/Postal Houston, TX 77053
Country United States
Residence 3 years or longer (If No,
previous addresses shown below)
Yes
SSN/SIN 0860
Date of Birth
Primary Phone 281-***-****
Preferred method of contact Primary Phone
Best time to contact you Morning
Email ad2r2g@r.postjobfree.com
Company Questions
GENERAL INFORMATION
Applicant Type: Truck Driver
If you answered YES to the question
above, will you require now or in the near
future employment visa sponsorship (i.e.,
H-1B visa)?
Are you currently employed? Yes
What date did your last employment end?
Do you read, write, and speak English? Yes
Enter start and end dates, location,
position, and reason for leaving:
Do you have a current TWIC card? No
Expiration date:
Have you ever been known by any other
name?
No
Enter name:
1
Please enter the names of any relatives
employed here:
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 NONE
Tractor and Semi-Trailer NONE
Tractor - Two Trailers NONE
Other Box Truck
June 2002-September 2022
Which safe driving awards do you hold and
from whom?
Best Delivery Driver Awards
EQUIPMENT (OWNER/OPERATORS ONLY)
Equipment Description (Tractor):
Type:
Year:
Make:
Model:
Color:
VIN:
Weight
Mileage
Fifth Wheel Height
First Reference:
Have you completed your registration for
the FMCSA Drug & Alcohol
Clearinghouse?
No
Applicant Workflow ID 2965693
Person ID 1996509
System ID 2965693
2
Licenses
License Number 227
Licensing Authority TX
Country US
License Class
Original Issue Date 08-10-2018
License Expiration Date 08-01-2024
Physical Expiration Date
Current License Yes
Commercial Driver License No
Endorsements
Tanker Endorsement No
HAZMAT Endorsement No
X Endorsement No
Doubles Triples Endorsement No
Other Endorsement No
Restrictions None
Employment / Unemployment
Texana
Company Texana
Contact / Supervisor Name
Start Date 12-2022
End Date 08-2023
Address
City, State/Province Zip/Postal Houston, TX
Country United States
Phone 281-***-****
Position Held Residential Trainer
Reason for leaving? Still employed
Were you terminated/discharged/laid off? No
Is this your current employer? Yes
May we contact this employer at this time? Yes
3
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?
Areas Driven
Miles driven weekly
Pay Range (cents/mile)
Most common truck driven
Most common trailer
Trailer length
Unemployment
Start Date 09-2022
End Date 12-2022
Comment
Brinks Inc
PLEASE DO NOT CONTACT
Company Brinks Inc
Contact / Supervisor Name
Start Date 12-2020
End Date 09-2022
Address
City, State/Province Zip/Postal Dallas, TX
Country United States
Phone 713-***-****
Position Held Non-CDL Driver
Reason for leaving? Laid Off
Were you terminated/discharged/laid off? Yes
Termination Explanation Laid Off
Is this your current employer? No
May we contact this employer at this time? No
Yes
4
Did you operate a commercial motor
vehicle?
Were you subject to the Federal Motor
Carrier or Transport Canada Safety
Regulations while employed/contracted by
this employer/contractor?
No
Did you perform any safety sensitive
functions in this job, regulated by DOT, and
subject to drug and alcohol testing?
Yes
Areas Driven
Miles driven weekly
Pay Range (cents/mile)
Most common truck driven Other
Most common trailer Other
Trailer length 31 feet or less
Unemployment
Start Date 03-2020
End Date 12-2020
Comment
FMCSR
Under FMCSR 391.15, are you currently
disqualified from driving a commercial
motor vehicle? [49 CFR 391.15]
No
Has your license, permit or privilege to
drive ever been suspended or revoked for
any reason? [49 CFR 391.21(b)(9)]
No
Have you ever been denied a license,
permit, or privilege to operate a motor
vehicle?[49 CFR 391.21(b)(9)]
No
Within the past two years, have you 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? [49 CFR 40.25(j)]
No
In the past three(3) years, have you ever
been convicted of any of the following
offenses: [49 CFR 391.15]:
Driving a commercial motor vehicle
with a blood alcohol concentration
·
No
5
("BAC") of .04 percent or more
Driving under the influence of
alcohol, as prescribed by state law
·
Refusal to undergo drug and
alcohol testing as required by any
jurisdiction for the enforcement of
Federal Motor Carrier Safety Act
regulations
·
Driving a commercial motor vehicle
under the influence of any 21
C.F.R. 1308.11 Schedule I
identified controlled substance, an
amphetamine, a narcotic drug, a
formulation of an amphetamine, or
a derivative of a narcotic drug
·
Transportation, possession, or
unlawful use of a 21 C.F.R.
1308.11 Schedule I identified
controlled substance,
amphetamines, narcotic drugs,
formulations of an amphetamine, or
derivatives of narcotic drugs while
you were on duty driving for a
motor carrier
·
Leaving the scene of an accident
while operating a commercial motor
vehicle
·
Or any other felony involving the
use of a commercial motor vehicle
·
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? No
Do you have any deferred prosecutions? No
Do you have criminal charges pending? No
No
6
Have you ever pled "guilty" to, been
convicted of, or pled "no contest" to a
felony?
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
Signature
Full Name Kerry Baines
IP Address 2601:2c6:8401:91
Signature Date/Time 08-20-2023 9:47 PM
By signing my application below, I agree to use an electronic signature to demonstrate my consent. An electronic signature is as legally binding as an ink signature. 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: 08-20-2023 9:47 PM
Signed:
Federal FCRA Summary of Rights Acknowledgment
By checking this box, I (a) acknowledge
that I have read and understand the
federal FCRA Summary of Rights and
have been given the opportunity to
copy/print the Summary of Rights and (b)
agree to use an electronic signature to
demonstrate my consent. An electronic
signature is as legally binding as an ink
signature.
Yes
PSP Disclosure and Authorization
By checking the box, I (a) acknowledge
that I have read and understand the PSP
Yes
7
Disclosure and Authorization and also
have been given the opportunity to
copy/print it, and (b) agree to use an
electronic signature to demonstrate my
consent. An electronic signature is as
legally binding as an ink signature.
FCRA Disclosure
By checking the box, I (a) acknowledge
that I have read and understand the above
and also have been given the opportunity
to copy/print it, and (b) agree to use an
electronic signature to demonstrate my
consent. An electronic signature is as
legally binding as an ink signature.
Yes
FCRA Authorization
By checking the box, I (a) acknowledge
that I have read and understand the above
and also have been given the opportunity
to copy/print it, and (b) agree to use an
electronic signature to demonstrate my
consent. An electronic signature is as
legally binding as an ink signature.
Yes
Employment Verification Acknowledgment and Release (DOT Drug and Alcohol) By checking the box, I (a) acknowledge
that I have read and understand the above
and also have been given the opportunity
to copy/print it, and (b) agree to use an
electronic signature to demonstrate my
consent. An electronic signature is as
legally binding as an ink signature.
Yes
Summary of Rights Under 15 U.S.C. Section 1681m(a) By checking the box, I (a) acknowledge
that I have read and understand the
Summary of Rights Under 15 U.S.C.
Section 1681m(a) and have been given
the opportunity to copy/print the 1681m
Summary of Rights and (b) agree to use
an electronic signature to demonstrate my
consent. An electronic signature is as
legally binding as an ink signature.
Yes
8
INVESTIGATIVE CONSUMER REPORT DISCLOSURE
By checking this box, I represent that I
understand and agree to the above
Investigative Consumer Report
Disclosure.
Yes
User Requested Copy
User requested a copy to be sent to this
email address
ad2r2g@r.postjobfree.com.
Yes
9
DISCLOSURE AND AUTHORIZATION TO REQUEST CONSUMER REPORTS & INVESTIGATIVE DISCLOSURE
Ryder System Inc. ('COMPANY') will obtain a consumer report and/or investigative consumer report ("Report") that contains background information about you from First Advantage Enterprise Screening Corporation ("First Advantage"), 1 Concourse Parkway NE Suite 200 Atlanta, GA 30328 (http://www.FADV.com), 1-866-***-****, as part of the hiring process for this position and for any future position for which you are considered. If you are hired, to the extent permitted by law, COMPANY may obtain further Reports from First Advantage throughout your employment for an employment purpose without providing further disclosure or obtaining additional consent. The Reports may include, but are not limited to, information regarding your character, general reputation, personal characteristics and standard of living, educational and employment history, drug/alcohol test results, OFAC/terrorist watch list, sex offender search, Social Security verification and address history, driving record and criminal record and accident history as required by the Federal Motor Carrier Safety Act, subject to any limitations imposed by applicable federal and state law. This information may be obtained through direct or indirect contact with public and private sources, including former employers, schools and public agencies or other sources. If an investigative consumer report is requested, in addition to the description above, the nature and scope of any such report will be employment verifications and references, or personal references.
The specific type of report most often requested is criminal record, driving record, accident history, and employment history. You have the right to request a complete disclosure of the nature and scope of the consumer report requested and/or prepared.
AUTHORIZATION
I have carefully read the foregoing Disclosure and this Authorization. By signing below, I consent to and authorize the COMPANY to obtain from First Advantage the Reports described above relating to me for employment purposes. I acknowledge receipt of a copy of the "A Summary of Your Rights Under the Fair Credit Reporting Act." Printed Name:
Kerry Baines
Social Security #:
0860
Signed Date: 08-20-2023
Kerry Baines
15319 Summerlyn Point Ln
Houston, TX 77053
Gender:
10
DISCLOSURE & AUTHORIZATION FOR BACKGROUND INVESTIGATION The Company will utilize the services of a third-party agency or consumer reporting agency to obtain a consumer report for purposes of evaluating your application, appointment and/or contract terms at the time of application and throughout your affiliation with the Company. The term "consumer report" includes communications by a third-party agency or consumer reporting agency bearing on your criminal background, driving record, education, prior employment, credit history, character or mode of living. Credit history will only be requested where such information is substantially related to the duties and responsibilities of the position for which you are applying or are employed in. Pursuant to the Fair Credit Reporting Act, the Company is required to obtain your permission prior to procuring the consumer report. By signing below, you hereby authorize the Company to procure report(s) on your background as described above from any third-party or consumer reporting agency contacted by the Company. You further authorize ongoing procurement of the above-mentioned report(s) at any time that you are considered for another position with the Company or at any time during your association with the Company. Printed Name:
Kerry Baines
Social Security #:
0860
Signed Date: 08-20-2023
Kerry Baines
15319 Summerlyn Point Ln
Houston, TX 77053
Gender:
11
IMPORTANT DISCLOSURE
REGARDING BACKGROUND REPORTS FROM THE PSP Online Service In connection with your application for employment with Ryder Integrated Logistics, Inc. DOT#165420 ("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 Ryder Integrated Logistics, Inc. DOT#165420 ("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:
Kerry Baines
Signed Date: 08-20-2023
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 08-20-2023
Date
X 0860
Social Security Number
Kerry Baines
15319 Summerlyn Point Ln
Houston, TX 77053
Gender:
X Kerry Baines
Print Name (First, MI, Last)
X
Signature
I, the above mentioned signer, hereby authorize Brinks Inc To release and forward in accordance with the following regulation, all known information pertaining to my alcohol and controlled substances testing/training records to Ryder Integrated Logistics, Inc. DOT#165420 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 Ryder Integrated Logistics, Inc., or to HireRight for the sole purpose of transmitting such records to Ryder Integrated Logistics, 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. 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 Ryder Integrated Logistics, Inc. or HireRight to review involves tests required by DOT. If any carrier (company/school) listed above furnishes Ryder Integrated Logistics, Inc. 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. 13
Summary of Rights Under 15 U.S.C. Section 1681m(a) You are hereby provided a summary of the following provisions of the Fair Credit Reporting Act, 15 U.S.C. 1681m(a): The following consumer reporting agencies will prepare the background report / consumer report for Ryder Integrated Logistics, Inc. DOT#165420 ('Company'):
Tenstreet
120 W. 3rd Street
Tulsa, OK 74103
Phone: 877-***-****
Email: ad2r2g@r.postjobfree.com
Web: http://www.tenstreet.com/drivers/
For Clearinghouse:
U.S. Federal Motor Carrier Safety Administration, of the Department of Transportation, ("FMCSA-DOT") 1200 New Jersey Avenue SE
Washington, DC 20590
Phone: 800-***-****, TTY 800-***-****
https://dataqs.fmcsa.dot.gov/Default.aspx
·
No consumer reporting agency utilized by the Company makes adverse decisions relating to your employment or contract relationship and no consumer reporting agency utilized by the Company is able to provide any specific reasons to you why an adverse decision relating to your employment or contract relationship may be taken or was taken based on a consumer report.
·
15 U.S.C. 1681j provides for the right to obtain a free copy of a consumer report on you from the consumer reporting agency which prepared your background report, under various circumstances, including but not limited to where you receive notice that an adverse action has been taken toward you based on the consumer report. In that instance, Section 1681j provides a right to a free copy of the report provided that you make the request within 60 days of the date that you received notice of the adverse action.
·
15 U.S.C. 1681i provides for the right to dispute, with a consumer reporting agency the accuracy or completeness of any information in a consumer report furnished by the agency.
·
14
INVESTIGATIVE CONSUMER REPORT DISCLOSURE
Ryder Integrated Logistics, Inc. DOT#165420 ("Company") will order an 'investigative consumer report' concerning you for employment purposes or, if you are an owner-operator (independent contractor), for the legitimate business purpose of evaluating your suitability for an independent contractor engagement pursuant to your written instructions. An 'investigative consumer report' is defined as a consumer report or portion thereof in which information on a consumer's character, general reputation, personal characteristics, or mode of living is obtained through personal interviews with neighbors, friends, or associates of the consumer reported on or with others with whom he is acquainted or who may have knowledge concerning any such items of information.
The investigative consumer report the Company will order concerning you will contain information concerning your character, general reputation, personal characteristics, and mode of living, obtained through personal interviews. You have the right to request the additional disclosures provided for under the Fair Credit Reporting Act, 15 U.S.C. 1681d(b), which reads as follows:
Any person who procures or causes to be prepared an investigative consumer report on any consumer shall, upon written request made by the consumer within a reasonable period of time after the receipt by him of the disclosure required by subsection (a)(1) of this section, make a complete and accurate disclosure of the nature and scope of the investigation requested. This disclosure shall be made in a writing mailed, or otherwise delivered, to the consumer not later than five days after the date on which the request for such disclosure was received from the consumer or such report was first requested, whichever is the later. At present, the specific 'nature and scope' of the investigative consumer report the Company may request is as follows: Employment Verifications, Motor Vehicle Reports, CDLIS, Criminal Records, and PSP. The report(s) will be requested from the following: Tenstreet
120 W. 3rd Street
Tulsa, OK 74103
Phone: 877-***-****
Email: ad2r2g@r.postjobfree.com
Web: http://www.tenstreet.com/drivers/
For Clearinghouse:
U.S. Federal Motor Carrier Safety Administration, of the Department of Transportation, ("FMCSA-DOT") 1200 New Jersey Avenue SE
Washington, DC 20590
Phone: 800-***-****, TTY 800-***-****
https://dataqs.fmcsa.dot.gov/Default.aspx
You have the right to request whether an investigative consumer report was ordered. You can also make a written request for a complete and accurate disclosure of the nature and scope of the investigation that was requested, request a copy of the report, a copy of any federal or state local notices of rights that may apply to you, or request the name, address and telephone number of the nearest unit of the consumer reporting agency designated to handle inquiries of each consumer reporting agency issuing an investigative consumer report about you, by sending a letter or email to the Company. You may also request and promptly receive from all such consumer reporting agencies free copies of any such investigative consumer reports. MARYLAND: You have the right to request additional disclosures from the Company regarding the nature and scope of the requested investigation.
MASSACHUSETTS: If you contact the Company, you have the right to know whether the Company ordered an investigative consumer report about you. You also have the right to ask the CRA for a copy of any such report. MINNESOTA: You have the right in most circumstances to submit a written request to the CRA for a complete and accurate disclosure of the nature and scope of any consumer report the Company ordered about you. The CRA must provide you with this disclosure within five business days after its receipt of your request or the report was requested by the Company, whichever date is later. NEW JERSEY: You have the right to submit a request to the CRA for a copy of any investigative consumer report the Company ordered about you.
NEW YORK: If you contact the Company, you have the right to know whether the Company ordered a consumer report or investigative consumer report about you. Shown above is the CRA's address and telephone number. You have the right to contact the CRA to inspect or receive a copy of any such report. A copy of Article 23-A of the Correction Law is provided in connection herewith. 15
WASHINGTON STATE: If you submit a written request to the Company, you have the right to a complete and accurate disclosure of the nature and scope of any investigative consumer report the Company ordered about you. You are entitled to this disclosure within five business days after the date your request is received or we ordered the report, whichever is later. You also have the right to request a written summary of your rights under the Washington Fair Credit Reporting Act. 16
DISCLOSURE AND AUTHORIZATION TO REQUEST CONSUMER REPORTS & INVESTIGATIVE DISCLOSURE
Ryder System Inc. ('COMPANY') will obtain a consumer report and/or investigative consumer report ("Report") that contains background information about you from First Advantage Enterprise Screening Corporation ("First Advantage"), 1 Concourse Parkway NE Suite 200 Atlanta, GA 30328 (http://www.FADV.com), 1-866-***-****, as part of the hiring process for this position and for any future position for which you are considered. If you are hired, to the extent permitted by law, COMPANY may obtain further Reports from First Advantage throughout your employment for an employment purpose without providing further disclosure or obtaining additional consent. The Reports may include, but are not limited to, information regarding your character, general reputation, personal characteristics and standard of living, educational and employment history, drug/alcohol test results, OFAC/terrorist watch list, sex offender search, Social Security verification and address history, driving record and criminal record and accident history as required by the Federal Motor Carrier Safety Act, subject to any limitations imposed by applicable federal and state law. This information may be obtained through direct or indirect contact with public and private sources, including former employers, schools and public agencies or other sources. If an investigative consumer report is requested, in addition to the description above, the nature and scope of any such report will be employment verifications and references, or personal references.
The specific type of report most often requested is criminal record, driving record, accident history,