Post Job Free
Sign in

United States Qualified Applicants

Location:
Waco, TX
Salary:
25.00 per hour
Posted:
November 05, 2024

Contact this candidate

Resume:

CMH Transport, Inc

*** ********* ****

Rocky Top, TN 37769

865-***-****

**-**-**** *:14:22PM CDT

IntelliApp

Thank you for your interest in Clayton Connect. To apply for a driving position, please complete our online application for employment. Incomplete information will delay the processing of your application or prevent it from being submitted. In compliance with Federal and State equal employment opportunity laws, qualified applicants are considered for all positions without regard to race, color, religion, sex, national origin, age, marital status, veteran status, non-job related disability, or any other protected group status.

Personal Information

Name Charles Wayne Coleman

Current Address 205 Mclennan Rd

Address 2 205 Mclennan Rd

City, State/Province Zip/Postal Mcgregor, TX 76657 Country United States

Residence 3 years or longer (If No,

previous addresses shown below)

No

Addresses Over last 3 years 4016 Oregon Ave Springfield Oregon 97478

SSN/SIN 8472

Date of Birth

Primary Phone 541-***-****

Cell Phone 541-***-****

Preferred method of contact Primary Phone

Best time to contact you Any

Email ******************@*****.***

Yes, I agree to receive information

concerning future opportunities or

promotions from CMH Transport, Inc by

email or other commercial electronic

communications.

Yes

Would you like to receive communication

from CMH Transport, Inc via text

message?

By participating, you consent to receive

text messages sent by an automatic

telephone dialing system, which may

Yes

1

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 CMH

Transport, Inc's service provider receives

in real time and logs your text messages

with CMH Transport, Inc.

Company Questions

GENERAL INFORMATION

What position are you applying for? Company Driver (CDL A) What division are you applying for? HouseSmart

Are you legally eligible for employment in

the United States?

Yes

Are you relocating from another State? No

Are you currently employed? No

What date did your last employment end? 02-29-2024 Do you read, write, and speak English? Yes

Have you ever worked for this company

before?

No

Enter start and end dates, location,

position, and reason for leaving:

Expiration date:

Please enter the names of any relatives

employed here:

Have you ever been known by any other

name?

No

Enter name:

How did you hear about us? Indeed

If "Driver Referral", please enter the

driver's name

If "Other", please explain

Have you completed your registration for

the FMCSA Drug & Alcohol

Clearinghouse?

Yes

In case of Emergency, notify (list name,

address, and phone):

Carla Wheeler 157 Knoop Ln Eugene

Oregon 97408 541-***-****

DRIVING EXPERIENCE

2

For each class of load, please enter start and end dates, and approximate number of total miles. If no experience in a class, enter "NONE". Manufactured Housing None

Oversized Dimension 12ft wide equipment on flatbed trailer Other None

Which safe driving awards do you hold and

from whom?

EDUCATION

List highest grade completed: Grade 12

List last school attended (name, city, and

state):

Waco High Waco,Tx.

PROFESSIONAL REFERENCES

List name, address, city, state, phone number, and relationship: First Reference: Savanna Rice 205 McLennan Rd

McGregor Tx 254-***-**** Neice

Second Reference: Harold Coleman 3918 Erath St Waco Tx 254-***-**** Brother

Licenses

License Number 074

Licensing Authority OR

Country US

License Class Class A

License Expiration Date 09-08-2030

DOT Medical Card Expiration Date 12-20-2024

Current License Yes

Commercial Driver License Yes

Endorsements

Tanker Endorsement No

HAZMAT Endorsement No

X Endorsement No

Doubles Triples Endorsement Yes

Other Endorsement No

Restrictions None

3

Employment / Unemployment

SEC Trucking

Company SEC Trucking

Start Date 08-2022

End Date 03-2024

Address 1047 56th PL

City, State/Province Zip/Postal Springfield, OR 97478 Country United States

Phone 541-***-****

Position Held Dump truck driver

Reason for leaving? Moved back to Texas

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 Oregon

Miles driven weekly 500-1000

Pay Range (cents/mile) 25 per hour

Most common truck driven Dump Truck

Most common trailer Other

Trailer length Other

Wood Recovery

Company Wood Recovery

Start Date 03-2021

End Date 08-2022

Address 29229 Milliron Rd

City, State/Province Zip/Postal Junction City, OR 97448 Country United States

4

Phone 541-***-****

Position Held Class A driver

Reason for leaving? Went to drive dump truck

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 Oregon, Washington

Miles driven weekly 1000-1500

Pay Range (cents/mile) 24 an hour

Most common truck driven Tractor-Trailer

Most common trailer Other

Trailer length 53 feet or more

Unemployed

PLEASE DO NOT CONTACT

Company Unemployed

Start Date 06-2020

End Date 06-2021

Address 4016 Oregon Ave

City, State/Province Zip/Postal Springfield, OR 97478 Country United States

Phone 541-***-****

Position Held Unployed

Reason for leaving? DUI in my own personal vehicle Were you terminated/discharged/laid off? Yes

Termination Explanation DUI in my own personal vehicle in my own driveway

Is this your current employer? No

5

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, regulated by DOT,

and subject to drug and alcohol testing?

Areas Driven

Miles driven weekly

Pay Range (cents/mile)

Most common truck driven

Most common trailer

Trailer length

Stapleton Timber And Excavation

Company Stapleton Timber And Excavation

Start Date 04-2015

End Date 06-2020

Address 3500 Commercial Ave

City, State/Province Zip/Postal Springfield, OR 97478 Country United States

Phone 541-***-****

Position Held Class A driver

Reason for leaving? No raise

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,

Yes

6

and subject to drug and alcohol testing?

Areas Driven Oregon

Miles driven weekly 1000-1500

Pay Range (cents/mile) 18 an hour

Most common truck driven Dump Truck

Most common trailer Flatbed

Trailer length 32 to 44 feet

Rexius Forest By Products

Company Rexius Forest By Products

Start Date 02-2007

End Date 04-2015

Address 1275 Bailey Hill Rd

City, State/Province Zip/Postal Eugene, OR 97402

Country United States

Phone 541-***-****

Position Held Class A driver

Reason for leaving? Got off road

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 Oregon, Washington,Idaho, Montana

Miles driven weekly 2500-3000

Pay Range (cents/mile) . 45 cpm

Most common truck driven Conventional Tractor

Most common trailer Doubles

Trailer length 53 feet or more

Evans Trucking Company

7

PLEASE DO NOT CONTACT

Company Evans Trucking Company

Start Date 02-2005

End Date 01-2007

Address Old Lorena Hwy

City, State/Province Zip/Postal Lorena, TX 76724

Country United States

Phone 000-***-****

Position Held Class A driver

Reason for leaving? Moved back to Oregon

Were you terminated/discharged/laid off? No

Is this your current employer? No

May we contact this employer at this time? No

Did you operate a commercial motor

vehicle?

Yes

Were you subject to the Federal Motor

Carrier or Transport Canada Safety

Regulations while employed/contracted by

this employer/contractor?

Yes

Did you perform any safety sensitive

functions in this job, regulated by DOT,

and subject to drug and alcohol testing?

Yes

Areas Driven Tx,Ok LA, Ar.

Miles driven weekly 2000-2500

Pay Range (cents/mile) .40 cpm

Most common truck driven Conventional Tractor

Most common trailer Van

Trailer length 53 feet or more

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)]

Yes

8

Please provide additional detail, including the dates of the suspension(s)/revocation(s): DUI in my own personal vehicle in my own driveway

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

("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

·

No

9

Vehicle Accident Record

Were you involved in any accidents/incidents with any vehicle in the last 7 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

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, 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 Charles Wayne Coleman

IP Address 2607:fb90:e639:8

Signature Date/Time 03-30-2024 2:14 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.

10

Signed Date: 03-30-2024 2:14 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

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

11

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

Clearinghouse Release

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

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

******************@*****.***.

Yes

12

DISCLOSURE FOR CONSUMER REPORTS

In connection with your employment or owner-operator (independent contractor) application, CMH Transport, Inc may order one or more consumer report(s) (commonly known as "background reports" or "background checks") about you from one or more consumer reporting agencies. If you are hired or engaged as an owner-operator (independent contractor), additional consumer reports may be obtained in connection with and throughout your employment for employment purposes or for the legitimate business purpose of evaluating you as an owner-operator.

To the extent allowed by law, the consumer reports may include information concerning your character, general reputation, personal characteristics, mode of living, drug and alcohol test results, motor vehicle records, driving records, criminal information, public court records, employment history (including names and dates of previous employers, reason for termination of employment, work experience, and accidents), social security number validation, education, licensure, or verification of other information supplied by you. Such reports may be obtained from private and public record sources, including sanctions databases, CDLIS, former employers, public court records, and federal, state, and other government agencies that maintain such records. Printed Name:

Charles Wayne Coleman

Social Security #:

8472

Signed Date: 03-30-2024

Charles Wayne Coleman

205 Mclennan Rd

205 Mclennan Rd

Mcgregor, TX 76657

541-***-****

Gender:

13

AUTHORIZATION FOR CONSUMER REPORTS

I authorize CMH Transport, Inc to obtain one or more consumer report(s) or investigative consumer report(s) about me. If hired or engaged as an owner-operator (independent contractor), I understand this authorization shall remain on file and shall serve as ongoing authorization for additional consumer reports or investigative consumer reports to be obtained from any consumer reporting agency at any time during my employment or contract period without asking me for authorization again. Printed Name:

Charles Wayne Coleman

Social Security #:

8472

Signed Date: 03-30-2024

Charles Wayne Coleman

205 Mclennan Rd

205 Mclennan Rd

Mcgregor, TX 76657

541-***-****

Gender:

14

IMPORTANT DISCLOSURE

REGARDING BACKGROUND REPORTS FROM THE PSP Online Service In connection with your application for employment with CMH Transport, 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 CMH Transport, 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:

Charles Wayne Coleman

Signed Date: 03-30-2024

15

16

Consent for Limited Queries of the Federal Motor Carrier Safety Administration (FMCSA) Drug and Alcohol Clearinghouse

I hereby provide consent to CMH Transport, Inc to conduct a limited query of the FMCSA Commercial Driver's License Drug and Alcohol Clearinghouse to determine whether drug or alcohol violation information about me exists in the Clearinghouse. I understand this consent shall remain on file and shall serve as ongoing consent for CMH Transport, Inc to conduct multiple limited queries of the Clearinghouse at any time during my employment or contract period without asking me for additional consent. I understand that if I refuse to provide consent for CMH Transport, Inc to conduct a limited query of the Clearinghouse, CMH Transport, Inc is required to prohibit me from performing safety-sensitive functions, including operating a commercial motor vehicle. I understand that if the limited query conducted by CMH Transport, Inc indicates that drug or alcohol information exists about me in the Clearinghouse, the FMCSA will not disclose that information to CMH Transport, Inc unless I give additional specific consent within the Clearinghouse. However, I understand that CMH Transport, Inc will be required to conduct a full query of the Clearinghouse within 24 hours after a limited query indicates that drug or alcohol information exists and that if I do not grant consent within the Clearinghouse for that full query I will be removed from performing safety-sensitive functions, including operating a commercial motor vehicle. 03-30-2024

Charles Wayne Coleman Date

17

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 03-30-2024

Date

X 8472

Social Security Number

Charles Wayne Coleman

205 Mclennan Rd

205 Mclennan Rd

Mcgregor, TX 76657

541-***-****

Gender:

X Charles Wayne Coleman

Print Name (First, MI, Last)

X

Signature

I, the above mentioned signer, hereby authorize SEC Trucking To release and forward in accordance with the following regulation, all known information pertaining to my alcohol and controlled substances testing/training records to CMH Transport, Inc

DISCLOSURE AND AUTHORIZATION UNDER 49 C.F.R. PART 391.23 INCLUDING DOT DRUG AND ALCOHOL INFORMATION

For purposes of an investigation in accordance with 49 C.F.R. Part 391.23, I authorize my previous employers, contractors (if owner-operator), and trucking schools, as applicable, to release and forward to CMH Transport, Inc ("Company") the following information for the past three (3) years:

1. DOT alcohol and controlled substance information in accordance with Parts 382 and 40 of the Federal Motor Carrier Safety Regulations (49 CFR Part 382 and 49 CFR Part 40, Section 40.25) limited to the following DOT regulated testing items, including pre-employment testing results: (i) alcohol tests with a result of 0.04 or higher; (ii) verified positive drug tests; (iii) refusals to be tested;

(iv) other violations of DOT agency drug and alcohol testing regulations; (v) information obtained from previous employers of a drug and alcohol rule violation; and (vi) documentation, if any, of completion of the return-to-duty process following a rule violation. 2. Safety performance history information in accordance with 49 CFR Part 391.23, which includes: employment dates, work history

(which may include position held, reason for leaving, any termination information, whether subject to the Federal Motor Carrier Safety Administration regulations, equipment experience, area driven, and other information as applicable) and accident information

(including accident date, nature of accident, whether it was preventable, whether there were injuries, fatalities, or hazardous materials involved, and copies of any accident report).

Pursuant to Section 391.23(i) of the Federal Motor Carrier Safety Regulations, you have the following rights with regard to the information released:

1. You have the right to make a written request at any time to review the information provided by previous employers, contractors (if owner-operator), or trucking schools, as applicable. 2. You have the right to have errors in the information corrected by the previous employer, contractor (if owner-operator), or trucking school, as applicable and for that employer, contractor (if owner-operator), or trucking school to re-send the corrected information. 3. You have the right to have a rebuttal statement attached to the alleged erroneous information if the previous employer, contractor (if owner-operator), or trucking school and you cannot agree on the accuracy of the information. 18

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 03-30-2024

Date

X 8472

Social Security Number

Charles Wayne Coleman

205 Mclennan Rd

205 Mclennan Rd

Mcgregor, TX 76657

541-***-****

Gender:

X Charles Wayne Coleman

Print Name (First, MI, Last)

X

Signature

I, the above mentioned signer, hereby authorize Wood Recovery To release and forward in accordance with the following regulation, all known information pertaining to my alcohol and controlled substances testing/training records to CMH Transport, Inc

DISCLOSURE AND AUTHORIZATION UNDER 49 C.F.R. PART 391.23 INCLUDING DOT DRUG AND ALCOHOL INFORMATION

For purposes of an investigation in accordance with 49 C.F.R. Part 391.23, I authorize my previous employers, contractors (if owner-operator), and trucking schools, as applicable, to release and forward to CMH Transport, Inc ("Company") the following information for the past three (3) years:

1. DOT alcohol and controlled substance information in accordance with Parts 382 and 40 of the Federal Motor Carrier Safety Regulations (49 CFR Part 382 and 49 CFR Part 40, Section 40.25) limited to the following DOT regulated testing items, including pre-employment testing results: (i) alcohol tests with a result of 0.04 or higher; (ii) verified positive drug tests; (iii) refusals to be tested;

(iv) other violations of DOT agency drug and alcohol testing regulations; (v) information obtained from previous employers of a drug and alcohol rule violation; and (vi) documentation, if any, of completion of the return-to-duty process following a rule violation. 2. Safety performance history information in accordance with 49 CFR Part 391.23, which includes: employment dates, work history

(which may



Contact this candidate