May Be Training Program
Resume:
Prime, Inc.
Springfield, MO ****3
**-**-**** *:40:01PM CST
IntelliApp
We are committed to a policy of Equal Employment Opportunity and will not discriminate against an applicant or employee on the basis of race, color, religion, creed, national origin or ancestry, sex, age, physical or mental disability, veteran or military status, genetic information, sexual orientation, marital status, or any other legally recognized protected basis under federal, state or local laws, regulations or ordinances. The information collected by this application is solely to determine suitability for employment, verify identity and maintain employment statistics on applicants. Applicants with disabilities may be entitled to reasonable accommodation under the terms of the Americans with Disabilities Act and certain state or local laws. A reasonable accommodation is a change in the way things are normally done which will ensure an equal employment opportunity without imposing undue hardship on the Company. Please inform the Company's personnel representative if you need assistance completing any forms or to otherwise participate in the application process. Please provide complete information. An incomplete application may affect your consideration for employment.
Personal Information
Referral Code: campaignium
Name Michael Dugas
Residence 3 years or longer (If No,
previous addresses shown below)
Yes
Current Address 627 Ridge Road
City, State/Province Zip/Postal Lafayette, LA 70506 Country
Residence 7 years or longer (If No,
previous addresses shown below)
Yes
SSN/SIN 3104
Date of Birth
Primary Phone 337-***-****
Email **********@*****.***
Did you speak with a recruiter? No
Who?
Please keep me updated about Prime Inc.
opportunities, events and offerings
through:
1
Yes, I agree to receive information
concerning future opportunities or
promotions from Prime, Inc. by email or
other commercial electronic
communications.
Yes
Would you like to receive communication
from Prime, Inc. via text message?
By participating, you consent to receive
text messages sent by an automatic
telephone dialing system, which may
contain recruiting/advertising messages.
Consent to these terms is not a condition
of being hired, contracted, or leased. You
may opt out at any time by texting STOP to
unsubscribe. You also agree that Prime,
Inc.'s service provider receives in real time
and logs your text messages with Prime,
Inc..
Yes
Company Questions
What name do you prefer to go by? Michael
AREA OF INTEREST
Are you interested in Prime's Student
Driver Training Program (working to get
your CDL)? (If you already have your CDL
then select 'NO')
Yes
Have you worked at Prime before? No
Last year worked?
Months of Tractor/Semi-Trailer Experience
that can be verified:
What is your preferred division? Unsure
Personal Non-related Reference
(must be non-related)
First Name: Cindy
Last Name: Istre
City: Abbeville
State: LA
Phone: 337-***-****
Relationship to you: Friend
Known for how long: 4 years
AREA OF INTEREST 2
Personal Non-related Reference
(must be non-related)
First Name: Chris
City: Youngsville
Last Name: Laughlin
State: Louisiana
Phone: 337-***-****
Relationship to you: Friend
Known for how long: 7 years
Emergency Contact
(related or otherwise)
First Name: Terry
Last Name: Dugas
City: Lafayette Louisiana
State: LA
Phone: 337-***-****
Relationship to you: Mother
Known for how long: 39 years
ADDITIONAL INFORMATION
Were you referred to Prime by an active
Prime driver?
No
Who was the Prime driver that referred
you?
Do you understand you will be required to
obtain a Tanker endorsement?
Yes
What is the issue date of your current
license?
10-29-2024
Does your current license match your
current state of residence?
Yes
Please explain:
Do you have any open traffic violation or
tickets pending or unpaid?
No
Have you failed or refused any drug or
alcohol tests in the last 3 years?
No
Have you completed a drug screen or
physical with any CDL school prior to
Prime (even if you did not complete
No
Personal Non-related Reference 3
training)?
Did you complete the CDL school training?
If no, please explain:
Licenses
Please enter all licenses you have held in the last 5 years License Number 420
Licensing Authority LA
Country US
License Class
License Expiration Date 09-14-2030
DOT Medical Card Expiration Date
Current License Yes
Commercial Driver License No
Endorsements None
Employment / Unemployment
Unemployment
Start Date 07-2024
End Date 11-2024
Comment
J way Tires
PLEASE DO NOT CONTACT
Company J way Tires
Contact / Supervisor Name John Lewis
Start Date 09-2019
End Date 07-2024
Address
City, State/Province Zip/Postal Lafayette, LA
Country United States
Phone 337-***-****
Position Held Shop foreman
Reason for leaving? Pay issues
Were you terminated/discharged/laid off? No
ADDITIONAL INFORMATION 4
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?
Areas Driven
Miles driven weekly
Pay Range (cents/mile)
Most common truck driven
Most common trailer
Trailer length
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
No
ADDITIONAL INFORMATION 5
or alcohol test by an employer to whom
you applied, but did not obtain
safety-sensitive transportation work
covered by DOT agency drug and alcohol
testing rules in past three years, or have
you ever tested positive or refused to test
on any DOT-mandated drug or alcohol
test?
Vehicle Accident Record
Were you involved in any accidents/incidents with any vehicle in the last 5 years (even if not at fault)?
No Accidents
Traffic Convictions \ Violations
Have you had any moving violations or traffic convictions in the past 5 years? No Violations
Criminal Record
An affirmative answer to the questions regarding criminal record will not automatically result in the denial of employment. An applicant's criminal record will be evaluated based on the job for which the applicant has applied. Have you ever been convicted of a crime? No
Do you have any deferred prosecutions? No
Do you have criminal charges pending? No
Have you ever pled "guilty" to, been
convicted of, or pled "no contest" to a
felony?
No
If you have any felony convictions, do you
currently hold a minister's permit to enter
or exit Canada?
No
Have you ever pled guilty to, been
convicted of, had prosecution deferred in
connection with, or pled "no contest" to a
misdemeanor?
No
ADDITIONAL INFORMATION 6
Signature
Full Name Michael Dugas
IP Address 2600:8807:2680:760:a972:3b43:94c1:47ea
Signature Date/Time 11-12-2024 6:40 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: 11-12-2024 6:40 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
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.
Yes
Additional Consent or Certification
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
Yes
ADDITIONAL INFORMATION 7
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
User Requested Copy
ADDITIONAL INFORMATION 8
User requested a copy to be sent to this
email address **********@*****.***.
Yes
ADDITIONAL INFORMATION 9
PRIME BACKGROUND CHECK AUTHORIZATION
I hereby authorize procurement of consumer report (s), to include any personal records required to satisfy DOT, FMCSA, or such related transportation safety laws and/or regulations, for purposes related to employment or contracted employment. I hereby request and authorize PRIME Inc. to completely investigate background for employment purposes, which may include, but is not limited to, any information related to my character, general reputation, personal characteristics, mode of living, criminal history, current work experience, past work experience, educational background, alcohol and drug tests, including failure to submit to alcohol or drug test, or any other information about me which may reflect upon my fitness for employment that is gathered from any individual, organization, entity, or Consumer Reporting Agency ( CSR ), or other source which may have knowledge concerning any such items of information.
Printed Name:
Michael Dugas
Social Security #:
3104
Signed Date: 11-12-2024
Michael Dugas
627 Ridge Road
Lafayette, LA 70506
ADDITIONAL INFORMATION 10
CONSUMER REPORT DISCLOSURE
In connection with my application for employment (including contract for services) with PRIME Inc., I understand that consumer reports which may contain public record information may be requested from a Consumer Reporting Agency (CRA). These reports may include, or otherwise contain, the following types of information: names and dates of current and previous employers, contain public information concerning my driving record, worker's compensation claims, criminal records, etc., from federal, state, and other agencies which maintain such records; state-provided driving records, as well as information from CRAs concerning previous driving record requests made by others from such state agencies. I authorize, without reservation, any party or agency contacted by a CRA to furnish this information.
In addition, I authorize PRIME Inc. to undertake, to the extent permitted by applicable state and federal laws, subsequent orders, inquiries, and/or requests for later-procured or follow-up CRA reports. These same applicant authorizations provided in the initial CRA Consumer Report Disclosure attach to any additional and/or subsequent CRA report generation. I understand that I have the right to make a request to a CRA, upon supplying proper identification, to request the nature and the substance of the information included in my file at the time of my request, including the sources of information; and the recipients of any report on me which the CRA has previously furnished within the three (3) year period preceding my request. I consent to PRIME Inc. obtaining the above information from a CRA, and I agree that such information which the CRA has or obtains, and the employment history stored by PRIME in the event of my hire, may be supplied by the CRA to other companies, which subscribe to the CRA's services.
Printed Name:
Michael Dugas
Social Security #:
3104
Signed Date: 11-12-2024
Michael Dugas
627 Ridge Road
Lafayette, LA 70506
ADDITIONAL INFORMATION 11
IMPORTANT DISCLOSURE
REGARDING BACKGROUND REPORTS FROM THE PSP Online Service In connection with your application for employment with Prime, Inc. ("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 Prime, Inc. ("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:
Michael Dugas
Signed Date: 11-12-2024
ADDITIONAL INFORMATION 12
TO BE READ AND SIGNED BY APPLICANT
I have read the Consumer Reporting Agency's and Prime's Disclosure and Release forms and agree to their terms. I also authorize the release of all alcohol and controlled substance testing results (or refusals to test) pursuant to 382.413 of the Federal Motors Carriers Safety Regulations and release this company from any and all liability of any type as a result of providing the above mentioned information to the above mentioned person.
By signing, applicant acknowledges and consents to PRIME's publication of the results of any alcohol and/or controlled substance test, including any pre-employment alcohol and/or controlled substance test, to external background reporting agencies, DAC reporting, and any equivalent background check and/or driver application reporting mechanisms. Printed Name: Michael Dugas
Social Security #: 3104
Signed Date: 11-12-2024
Signed:
TO BE READ AND SIGNED BY APPLICANT 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 Prime, Inc. ('Company'): Driver IQ
4500 S. 129th East Ave.
Suite 127
Tulsa, OK 74134
********@******.***
DriverFACTS
5051 E. Orangethorpe Ave
Suite E265
Anaheim, CA 92807
www.DriverRebuttal.com
NIC Federal, LLC
4601 N. Fairfax Drive
Suite 1010
Arlington, VA 22203
Inverify
P.O Box 351567
Westminster, CO 80035
www.inverify.net
HireRight, LLC
Attn: Consumers Dept.
14002 E 21st Street
Suite 1200
Tulsa, OK 74134
Phone: 866-***-****
Fax: 918-***-****
Email: ***************@*********.***
Web: http://www.hireright.com/applicants
Thomas and Thorngren
One Vantage Way
Suite A-105
Nashville, TN 37228
www.thomas-and-company.com
Asurint
P.O. Box 14730
Cleveland, OH 44114
https://www.asurint.com/candidates
Uconfirm
P.O.Box 1971
Woodstock, GA 30188
www.uconfirm.com
Explore Information Services, LLC Supervision
2750 Blue Water Road
Suite 200
·
TO BE READ AND SIGNED BY APPLICANT 14
Egan, MN 55121
http://www.esupervision.com/
Equifax / The Work Number
11432 Lackland
St. Louis, MO 63146
www.theworknumber.com
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
For Pre-Employment Screening Program (PSP):
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
Tenstreet
120 W. 3rd Street
Tulsa, OK 74103
Phone: 877-***-****
Email: *******@*********.***
Web: http://www.tenstreet.com/drivers/
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.
·
TO BE READ AND SIGNED BY APPLICANT 15
PRIME BACKGROUND CHECK AUTHORIZATION
I hereby authorize procurement of consumer report (s), to include any personal records required to satisfy DOT, FMCSA, or such related transportation safety laws and/or regulations, for purposes related to employment or contracted employment. I hereby request and authorize PRIME Inc. to completely investigate background for employment purposes, which may include, but is not limited to, any information related to my character, general reputation, personal characteristics, mode of living, criminal history, current work experience, past work experience, educational background, alcohol and drug tests, including failure to submit to alcohol or drug test, or any other information about me which may reflect upon my fitness for employment that is gathered from any individual, organization, entity, or Consumer Reporting Agency ( CSR ), or other source which may have knowledge concerning any such items of information.
Employer / Contractor / Educational Institution:
J way Tires
Printed Name:
Michael Dugas
Social Security #:
3104
Signed Date: 11-12-2024
Michael Dugas
627 Ridge Road
Lafayette, LA 70506
TO BE READ AND SIGNED BY APPLICANT 16
CONSUMER REPORT DISCLOSURE
In connection with my application for employment (including contract for services) with PRIME Inc., I understand that consumer reports which may contain public record information may be requested from a Consumer Reporting Agency (CRA). These reports may include, or otherwise contain, the following types of information: names and dates of current and previous employers, contain public information concerning my driving record, worker's compensation claims, criminal records, etc., from federal, state, and other agencies which maintain such records; state-provided driving records, as well as information from CRAs concerning previous driving record requests made by others from such state agencies. I authorize, without reservation, any party or agency contacted by a CRA to furnish this information.
In addition, I authorize PRIME Inc. to undertake, to the extent permitted by applicable state and federal laws, subsequent orders, inquiries, and/or requests for later-procured or follow-up CRA reports. These same applicant authorizations provided in the initial CRA Consumer Report Disclosure attach to any additional and/or subsequent CRA report generation. I understand that I have the right to make a request to a CRA, upon supplying proper identification, to request the nature and the substance of the information included in my file at the time of my request, including the sources of information; and the recipients of any report on me which the CRA has previously furnished within the three (3) year period preceding my request. I consent to PRIME Inc. obtaining the above information from a CRA, and I agree that such information which the CRA has or obtains, and the employment history stored by PRIME in the event of my hire, may be supplied by the CRA to other companies, which subscribe to the CRA's services.
Employer / Contractor / Educational Institution:
J way Tires
Printed Name:
Michael Dugas
Social Security #:
3104
Signed Date: 11-12-2024
Michael Dugas
627 Ridge Road
Lafayette, LA 70506
TO BE READ AND SIGNED BY APPLICANT 17
A Summary of Your Rights Under the Fair Credit Reporting Act Para informacion en espanol, visite www.consumerfinance.gov/learnmore o escribe a la Consumer Financial Protection Bureau, 1700 G Street N.W., Washington, DC 20552.
A Summary of Your Rights Under the Fair Credit Reporting Act The federal Fair Credit Reporting Act (FCRA) promotes the accuracy, fairness, and privacy of information in the files of consumer reporting agencies. There are many types of consumer reporting agencies, including credit bureaus and specialty agencies (such as agencies that sell information about check writing histories, medical records, and rental history records). Here is a summary of your major rights under FCRA. For more information, including information about additional rights, go to www.consumerfinance.gov/learnmore or write to: Consumer Financial Protection Bureau, 1700 G Street N.W., Washington, DC 20552.
You must be told if information in your file has been used against you. Anyone who uses a credit report or another type of consumer report to deny your application for credit, insurance, or employment - or to take another adverse action against you - must tell you, and must give you the name, address, and phone number of the agency that provided the information.
·
You have the right to know what is in your file. You may request and obtain all the information about you in the files of a consumer reporting agency (your "file disclosure"). You will be required to provide proper identification, which may include your Social Security number. In many cases, the disclosure will be free. You are entitled to a free file disclosure if:
a person has taken adverse action against you because of information in your credit report;
you are the victim of identity theft and place a fraud alert in your file;
your file contains inaccurate information as a result of fraud;
you are on public assistance;
you are unemployed but expect to apply for employment within 60 days. In addition, all consumers are entitled to one free disclosure every 12 months upon request from each nationwide credit bureau and from nationwide specialty consumer reporting agencies. See www.consumerfinance.gov/learnmore for additional information.
·
You have the right to ask for a credit score. Credit scores are numerical summaries of your credit-worthiness based on information from credit bureaus. You may request a credit score from consumer reporting agencies that create scores or distribute scores used in residential real property loans, but you will have to pay for it. In some mortgage transactions, you will receive credit score information for free from the mortgage lender.
·
You have the right to dispute incomplete or inaccurate information. If you identify information in
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