A Driver Carrier
Resume:
Crete Carrier Corporation
Lincoln, NE 68528
**-**-**** *:47:46PM CDT
Signature
Personal Information
Name Terry Dwayne Johnston
Current Address
City, State/Province Zip/Postal
Country
Residence 5 years or longer (If No,
previous addresses shown below)
Yes
SSN/SIN 2422
Date of Birth
Primary Phone 970-***-****
Cell Phone 970-***-****
Email ********@*****.***
Yes, I agree to receive information
concerning future opportunities or
promotions from Crete Carrier Corporation
by email or other commercial electronic
communications.
Yes
Would you like to receive communication
from Crete Carrier Corporation 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 Crete
Carrier Corporation's service provider
receives in real time and logs your text
messages with Crete Carrier Corporation.
Yes
Signature
Full Name Terry Dwayne Johnston
IP Address 2607:fb90:6ef9:2
Signature Date/Time 03-17-2022 1:47 PM
1
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 my check of this box, I represent that I
understand and agree to the above
Important Disclosure Regarding
Background Reports from the PSP Online
Service and Authorization, and, by
checking this box, I intend to execute this
document by electronic signature and
consent to the use of my electronic
signature to give effect to this document.
Yes
Additional Consent or Certification
By my check of this box, I represent that I
understand and agree to all of the above
disclosures, notices, authorizations,
releases, and certifications contained in
the above Disclosure and Authorization,
and, by checking this box, I intend to
execute this document by electronic
signature and consent to the use of my
electronic signature to give effect to this
document.
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
2
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 my check of this box, I represent that I
understand and agree to the above
Disclosure and Authorization for Release
of Information for Employment Purposes
49 CFR Part 391.23, DOT Drug and
Alcohol Testing, and, by checking this box,
I intend to execute this document by
electronic signature and consent to the use
of my electronic signature to give effect to
this document.
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
Yes
3
Disclosure.
User Requested Copy
User requested a copy to be sent to this
email address ********@*****.***.
Yes
4
DISCLOSURE FOR CONSUMER REPORTS
In connection with your employment or owner-operator (independent contractor) application, Crete Carrier Corporation and its division of Shaffer Trucking 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 history, 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 (including but not limited to CDLIS Central Site, CDLIS Master Pointer Record data and your driver record from the jurisdiction identified in the CDLIS data, in accordance with applicable state law and the Driver Privacy Protection Act), former employers, public court records, and federal, state, and other government agencies that maintain such records. Printed Name:
Terry Dwayne Johnston
Social Security #:
2422
Signed Date: 03-17-2022
Terry Dwayne Johnston
Gender:
5
AUTHORIZATION FOR CONSUMER REPORTS
I authorize Crete Carrier Corporation and its division of Shaffer Trucking 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:
Terry Dwayne Johnston
Social Security #:
2422
Signed Date: 03-17-2022
Terry Dwayne Johnston
Gender:
6
IMPORTANT DISCLOSURE
REGARDING BACKGROUND REPORTS FROM THE PSP Online Service In connection with your application for employment with Crete Carrier Corporation and its division of Shaffer Trucking ("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 Crete Carrier Corporation and its division of Shaffer Trucking ("Prospective Employer") to access the FMCSA Pre-Employment Screening Program (PSP) system to seek information regarding my commercial driving safety record and information regarding my safety inspection history. I understand that I am authorizing the release of safety performance information including crash data from the previous five (5) years and inspection history from the previous three (3) years. I understand and acknowledge that this release of information may assist the Prospective Employer to make a determination regarding my suitability as an employee. I further understand that neither the Prospective Employer nor the FMCSA contractor supplying the crash and safety information has the capability to correct any safety data that appears to be incorrect. I understand I may challenge the accuracy of the data by submitting a request to https://dataqs.fmcsa.dot.gov. If I challenge crash or inspection information reported by a State, FMCSA cannot change or correct this data. I understand my request will be forwarded by the DataQs system to the appropriate State for adjudication. I understand that any crash or inspection in which I was involved will display on my PSP report. Since the PSP report does not report, or assign, or imply fault, I acknowledge it will include all CMV crashes where I was a driver or co-driver and where those crashes were reported to FMCSA, regardless of fault. Similarly, I understand all inspections, with or without violations, will appear on my PSP report, and State citations associated with FMCSR violations that have been adjudicated by a court of law will also appear, and remain, on my PSP report. I have read the above Disclosure Regarding Background Reports provided to me by Prospective Employer and I understand that if I sign this Disclosure and Authorization, Prospective Employer may obtain a report of my crash and inspection history. I hereby authorize Prospective Employer and its employees, authorized agents, and/or affiliates to obtain the information authorized above. Printed Name:
Terry Dwayne Johnston
Signed Date: 03-17-2022
7
Consent for Limited Queries of the Federal Motor Carrier Safety Administration (FMCSA) Drug and Alcohol Clearinghouse
I hereby provide consent to Crete Carrier Corporation and its division of Shaffer Trucking (hereinafter collectively referred to as "Crete Carrier Corporation") 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 Crete Carrier Corporation 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 Crete Carrier Corporation to conduct a limited query of the Clearinghouse, Crete Carrier Corporation 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 Crete Carrier Corporation indicates that drug or alcohol information exists about me in the Clearinghouse, the FMCSA will not disclose that information to Crete Carrier Corporation unless I give additional specific consent within the Clearinghouse. However, I understand that Crete Carrier Corporation 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. 03-17-2022
Terry Dwayne Johnston Date
8
DISCLOSURE AND AUTHORIZATION
Disclosure and Authorization for Procurement/Release of Information for Employment Purposes - Background Information: Disclosure is hereby made that Crete Carrier Corporation and its division of Shaffer Trucking (hereinafter collectively referred to as "Crete Carrier Corporation") may request, for lawful employment purposes, background information about you. I hereby authorize Crete Carrier Corporation and its employees and agents to contact all of the following, without limitation, and authorize any of the following persons or entities ("Suppliers") to disclose information about me to Crete Carrier Corporation and its employees and agents: law enforcement and all other federal, state and local agencies, learning institutions (including public and private schools, colleges and universities), testing agencies, information service bureaus, record/data repositories, courts (federal, state and local), motor vehicle record agencies, my past or present employers, the military, and all other individuals and sources with any information about or concerning me. The information that can be disclosed includes, but is not limited to, information concerning my employment history, education, motor vehicle history, public court records, and military service. I hereby authorize Crete Carrier Corporation and its employees and agents to obtain the above listed information in connection with my application for employment or driver qualification, and, if I am hired or qualified, to: (i) obtain additional information in connection with my application for employment or qualification, and (ii) to obtain additional information in connection with the continuation of my employment, qualification, promotion, retention, or other lawful employment purposes. I authorize Crete Carrier Corporation to retain this document on file to act as ongoing authorization for the procurement and possession of the information at any time during my employment or qualification. Disclosure and Authorization for Procurement/Release of Information for Employment Purposes 49 CFR Part 391.23 DOT Drug/Alcohol Testing: In accordance with DOT Regulation 49 CFR Part 391.23 and 49 CFR Part 40, each as applicable, I hereby authorize release of my DOT-regulated drug and alcohol testing records by my past or present DOT-regulated employer(s) to Crete Carrier Corporation. I understand that information/documents released pursuant to this section is limited to the following DOT-regulated testing items, including pre-employment testing results, occurring during the previous three (3) years: (i) alcohol tests with a result of 0.04 or higher; (ii) verified positive drug tests; (iii) refusals to be tested (including adulterated and/or substituted tests); (iv) other violations of DOT drug and alcohol testing regulations (i.e., violations of 49 CFR 382 Subpart B); (v) information obtained from previous employers of a drug and alcohol rule violation; and (vi) any documentation of completion of the return-to-duty process following a rule violation. If any of my past or present employers furnishes Crete Carrier Corporation with information concerning items (i) through (vi) above, I also authorize such company to furnish the following information, if applicable: (i) dates of my negative drug and/or alcohol tests and/or tests with results below 0.04 during the previous three (3) years; and (ii) the name and phone number of any substance abuse professional who evaluated me during the previous three (3) years. I authorize Crete Carrier Corporation to retain this document on file to act as ongoing authorization for the procurement and possession of the information at any time during my employment or qualification. Authorization for Release of Employment Information:I agree that if I am hired or qualified, I authorize Crete Carrier Corporation to supply and release my employment/qualification history with Crete Carrier Corporation (excepting my drug and alcohol testing records, which is subject to a separate consent) to any entity for legally permissible purposes. I authorize Crete Carrier Corporation to retain this document on file to act as ongoing authorization permitting the supply and release of the information.
Release: In exchange for Crete Carrier Corporations consideration of my application for employment or qualification, I agree not to file or pursue any complaints, claims, or legal actions of any kind against any Supplier, including my past or present employers, that provides information about me to Crete Carrier Corporation or its employees and agents in accordance with the terms and intent of any authorizations or releases executed by me. I also agree not to file or pursue any complaints, claims, or legal actions against Crete Carrier Corporation or any of its employees and agents, which arise out of their efforts to obtain, supply, or release any information about me from or to any source. FMCSA Notification of Driver Rights: In compliance with 49 CFR 391.23 and 49 CFR Part 40, disclosure is hereby made that the information you provide regarding your previous employers will be utilized by Crete Carrier Corporation, and Crete Carrier Corporation will contact your previous employers for the purpose of investigating your safety performance history. You have certain rights regarding the safety performance history information that will be provided to Crete Carrier Corporation. You hereby acknowledge that: i) I have the right to review information provided by previous employers; ii) I have the right to have errors in the information corrected by the previous employer and for that previous employer to re-send the corrected information to Crete Carrier Corporation; iii) I have the right to have a rebuttal statement attached to the alleged erroneous information, if the previous employer and I cannot agree on the accuracy of the information. I also understand that if I have had a previous DOT regulated employment history in the preceding three (3) years and wish to review my previous employer-provided investigative information, I must submit a written request to Crete Carrier Corporation. This may be done at any time, including when applying, or as late as thirty (30) days after being employed or being notified of denial of employment. Crete Carrier Corporation must provide this information within five (5) business days of receiving the written request. If Crete Carrier Corporation has not yet received the requested information from the previous employer, then the five (5) day deadline will begin when the requested safety performance history is received. If I have not arranged to pick up or receive the requested records within thirty (30) days of Crete Carrier Corporation making them available, then Crete Carrier Corporation will consider you to have waived your request to review the record. All written requests for records must be sent to the attention of Safety Department Records Request, 400 NW 56th Street, Lincoln, NE 68528. Electronic Notification of Job Opportunities: I acknowledge that I may elect, but am under no obligation, to receive electronic notification of future job opportunities with Crete Carrier Corporation via email. By providing my email information I elect to receive and authorize Crete Carrier Corporation to provide me email notification and information relating to employment/qualification by Crete Carrier Corporation. Certification: By signing below, I certify that: (i) all information provided by me to Crete Carrier Corporation is true, complete and accurate; (ii) I have read and fully understand all disclosures, authorizations and releases provided to me; (iii) prior to signing, I was given an opportunity to ask questions and to have those questions answered to my satisfaction; (iv) I execute all authorizations and releases voluntarily and with the knowledge that the information provided to Crete Carrier Corporation could affect my eligibility for employment, promotion, retention, qualification, or other lawful purpose; (v) I understand that I have been given an opportunity to review all documents provided to me with legal counsel prior to signing; (vi) I authorize Crete Carrier Corporation and any person or entity contacted by Crete Carrier Corporation to furnish information in accordance with the terms and intent of the applicable authorization or release; and (vii) I agree that all authorizations or releases in original, facsimile, photographic, or electronic (including electronically signed) 9
form are as valid as an original.
Printed Name: Terry Dwayne Johnston
Social Security #: 2422
Signed Date: 03-17-2022
Signed:
10
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 03-17-2022
Date
X 2422
Social Security Number
Terry Dwayne Johnston
Gender:
X Terry Dwayne Johnston
Print Name (First, MI, Last)
X
Signature
I, the above mentioned signer, hereby authorize Navajo Express, 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 Crete Carrier Corporation DISCLOSURE AND AUTHORIZATION
DISCLOSURE AND AUTHORIZATION FOR RELEASE OF INFORMATION FOR EMPLOYMENT PURPOSES 49 CFR PART 391.23, DOT DRUG AND ALCOHOL TESTING
In accordance with DOT Regulation 49 CFR Part 391.23 and 49 CFR Part 40, each as applicable, I hereby authorize release of my DOT-regulated drug and alcohol testing records by the DOT-regulated employer(s) listed herein to Crete Carrier Corporation and its division of Shaffer Trucking (hereinafter collectively referred to as "Crete Carrier Corporation"), HireRight, LLC, Driver iQ
(transportation division of Cisive), Tenstreet, or another consumer reporting or other agency ("Agency") for the purpose of the Agency transmitting such records to Crete Carrier Corporation. I understand that information/documents released pursuant to this section is limited to the following DOT-regulated testing items, including pre-employment testing results, occurring during the previous three (3) years: (i) alcohol tests with a result of 0.04 or higher; (ii) verified positive drug tests; (iii) refusals to be tested (including adulterated and/or substituted tests); (iv) other violations of DOT drug and alcohol testing regulations (i.e., violations of 49 CFR 382 Subpart B); (v) information obtained from previous employers of a drug and alcohol rule violation; and (vi) any documentation of completion of the return-to-duty process following a rule violation. If any company listed herein furnishes Crete Carrier Corporation or the Agency with information concerning items (i) through (vi) above, I also authorize such company to furnish the following information, if applicable: (i) dates of my negative drug and/or alcohol tests and/or tests with results below 0.04 during the previous three (3) years; and (ii) the name and phone number of any substance abuse professional who evaluated me during the previous three (3) years. List all DOT-regulated employers you have applied with and/or worked for in a safety-sensitive function during the previous three (3) years. If necessary, attach additional pages, including the date, your name, social security number and signature. 11
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 03-17-2022
Date
X 2422
Social Security Number
Terry Dwayne Johnston
Gender:
X Terry Dwayne Johnston
Print Name (First, MI, Last)
X
Signature
I, the above mentioned signer, hereby authorize Indian Creek Express To release and forward in accordance with the following regulation, all known information pertaining to my alcohol and controlled substances testing/training records to Crete Carrier Corporation DISCLOSURE AND AUTHORIZATION
DISCLOSURE AND AUTHORIZATION FOR RELEASE OF INFORMATION FOR EMPLOYMENT PURPOSES 49 CFR PART 391.23, DOT DRUG AND ALCOHOL TESTING
In accordance with DOT Regulation 49 CFR Part 391.23 and 49 CFR Part 40, each as applicable, I hereby authorize release of my DOT-regulated drug and alcohol testing records by the DOT-regulated employer(s) listed herein to Crete Carrier Corporation and its division of Shaffer Trucking (hereinafter collectively referred to as "Crete Carrier Corporation"), HireRight, LLC, Driver iQ
(transportation division of Cisive), Tenstreet, or another consumer reporting or other agency ("Agency") for the purpose of the Agency transmitting such records to Crete Carrier Corporation. I understand that information/documents released pursuant to this section is limited to the following DOT-regulated testing items, including pre-employment testing results, occurring during the previous three (3) years: (i) alcohol tests with a result of 0.04 or higher; (ii) verified positive drug tests; (iii) refusals to be tested (including adulterated and/or substituted tests); (iv) other violations of DOT drug and alcohol testing regulations (i.e., violations of 49 CFR 382 Subpart B); (v) information obtained from previous employers of a drug and alcohol rule violation; and (vi) any documentation of completion of the return-to-duty process following a rule violation. If any company listed herein furnishes Crete Carrier Corporation or the Agency with information concerning items (i) through (vi) above, I also authorize such company to furnish the following information, if applicable: (i) dates of my negative drug and/or alcohol tests and/or tests with results below 0.04 during the previous three (3) years; and (ii) the name and phone number of any substance abuse professional who evaluated me during the previous three (3) years. List all DOT-regulated employers you have applied with and/or worked for in a safety-sensitive function during the previous three (3) years. If necessary, attach additional pages, including the date, your name, social security number and signature. 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 03-17-2022
Date
X 2422
Social Security Number
Terry Dwayne Johnston
Gender:
X Terry Dwayne Johnston
Print Name (First, MI, Last)
X
Signature
I, the above mentioned signer, hereby authorize Indian Creek Express To release and forward in accordance with the following regulation, all known information pertaining to my alcohol and controlled substances testing/training records to Crete Carrier Corporation DISCLOSURE AND AUTHORIZATION
DISCLOSURE AND AUTHORIZATION FOR RELEASE OF INFORMATION FOR EMPLOYMENT PURPOSES 49 CFR PART 391.23, DOT DRUG AND ALCOHOL TESTING
In accordance with DOT Regulation 49 CFR Part 391.23 and 49 CFR Part 40, each as applicable, I hereby authorize release of my DOT-regulated drug and alcohol testing records by the DOT-regulated employer(s) listed herein to Crete Carrier Corporation and its division of Shaffer Trucking (hereinafter collectively referred to as "Crete Carrier Corporation"), HireRight, LLC, Driver iQ
(transportation division of Cisive), Tenstreet, or another consumer reporting or other agency ("Agency") for the purpose of the Agency
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