Logiflex Inc
Park Ridge, IL *****
847-***-**** Ext. 400
**-**-**** *:28:23PM CST
IntelliApp
Thank you for your interest in Logiflex Inc. 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 Raymond Edwin Gilson
Residence 3 years or longer (If No,
previous addresses shown below)
Yes
Current Address 9230 44ave
Address 2 9230 44ave
City, State/Province Zip/Postal Sebastian, FL 32958 Country United States
SSN/SIN 8241
Date of Birth
Primary Phone 561-***-****
Cell Phone 561-***-****
Preferred method of contact Cell Phone
Best time to contact you Any
Email adwl4d@r.postjobfree.com
Yes, I want to receive information and
communications from Logiflex Inc
concerning future opportunities or
promotions
Yes
Yes, I want to receive text messages from
Logiflex Inc. *By participating, you consent
to receive text messages sent by an
automatic telephone dialing system.
Consent to these terms is not a condition
of hire. You may opt out at any time by
texting STOP to unsubscribe. Message
and Data Rates May Apply.
Yes
1
Company Questions
GENERAL INFORMATION
What position are you applying for? Company Driver If you answered "Owner Operator" select
yes.
No
EQUIPMENT (OWNER/OPERATORS ONLY)
Equipment Description (Tractor):
Type:
Year:
Make:
Model:
Color:
VIN:
Weight
Mileage
Fifth Wheel Height
What location are you applying for?
Are you legally eligible for employment in
the United States?
Yes
Are you currently employed? No
What date did your last employment end? Jan 2 2017 Do you read, write, and speak English? Yes
Have you ever worked for this company
before?
No
Enter start and end dates, location,
position, rate of pay, and reason for
leaving:
Do you have a current TWIC card? Yes
Expiration date: 04/2019
Please enter the names of any relatives
employed here:
None
Have you ever been known by any other
name?
No
Enter name:
How did you hear about us? Web
If "Driver Referral", please enter the
driver's name
2
If "Other", please explain
In case of Emergency, notify (list name,
address, and phone):
Marilyn longstreest 4949 n a1a fort pierce
Fla 772-***-****
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 Major electricity com 1973 1974 del to sugar refineries electrical supplys
Tractor and Semi-Trailer Landspan2003 to 2011 Lakeland Fla dry van haul fright for southeastern also ups
out of Atlanta game Fontana CA empire
exp Inc 2011 Oct 5 to Jan 2 2017 past 5
yrs del has mat loads to Quebec and
Ontario MB,SK,AB,YT,then to Alaska
was53ft dry van others 3Axel tank carry
cyanide to gold mines
Tractor - Two Trailers Did double trl
Other Tank 3 axel
Which safe driving awards do you hold
and from whom?
None
EDUCATION
List highest grade completed: Grade 12
List last school attended (name, city, and
state):
North Miami Sr high north Miami fla
PERSONAL REFERENCES
List name, address, city, state, phone number, and relationship: First Reference: Smith 1440 S ocean Blvd pompano fla 33062 954-***-****
Second Reference: ROBERT HELSETH 1695 OLD DIXIE
VERO BEACH FLA 329**-***-*** 7445
Licenses
License Number 620
State/Province FL
Country United States
License Class Class A
License Expiration Date 12-22-2017
Physical Expiration Date 10-05-2017
Current License Yes
3
Commercial Driver License Yes
Endorsements
Tanker Endorsement Yes
HAZMAT Endorsement Yes
Hazmat Expiration Date 12-22-2017
X Endorsement Yes
Doubles Triples Endorsement Yes
Other Endorsement No
Employment / Unemployment
Empire Express
Company Empire Express
Start Date 10-2011
End Date 02-2017
Address 999 Channel Ave
City, State/Province Zip/Postal Memphis, TN 38113
Country United States
Phone 901-***-****
Fax 901-***-****
Position Held
Reason for leaving? Personal
Were you terminated/discharged/laid off? No
Is this your current employer? Yes
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 48 states +Canada
Miles driven weekly 2000-2500
Pay Range (cents/mile) .52
4
Most common truck driven Tractor-Trailer
Most common trailer Tank Trailer
Trailer length 45 to 52 feet
Land Span
Company Land Span
Start Date 08-2003
End Date 02-2011
Address 1120 Griffn rd
City, State/Province Zip/Postal Lakeland, FL
Country United States
Phone 800-***-****
Position Held Otr
Reason for leaving? High salary
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 USA 48 states
Miles driven weekly 2000-2500
Pay Range (cents/mile) .18 to .23
Most common truck driven Tractor-Trailer
Most common trailer Van
Trailer length 53 feet or more
5
Military
Branch of Service Navy
Start Date 06-1968
End Date 05-1970
Can you obtain your DD214? Yes
Rank at discharge Airman
Trucking School
Start Date 08-1998
End Date 08-1998
School Swift
City, State/Province Greenville Sc, SC
Country United States
Phone
Did you graduate? Yes
Were you subject to the Federal Motor
Carrier or Transport Canada Safety
Regulations while attending this truck
school?
Yes
Did you perform any safety sensitive
functions at this truck school, regulated by
DOT, and subject to drug and alcohol
testing?
Yes
GPA
Hours of Instruction 50
Border Crossing No
Log Books Yes
Federal Motor Carrier Regulations Yes
Hazardous Materials Yes
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
6
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
or alcohol test by an employer to whom
you applied, but did not obtain
safety-sensitive transportation work
covered by DOT agency drug and alcohol
testing rules in past three years, or have
you ever tested positive or refused to test
on any DOT-mandated drug or alcohol
test?
No
Vehicle Accident Record
Were you involved in any accidents/incidents with any vehicle in the last 5 years (even if not at fault)?
No Accidents
Traffic Convictions \ Violations
Have you had any moving violations or traffic convictions in the past 3 years? No Violations
Criminal Record
Have you ever been convicted of a crime? Yes
Comment Misdemeanor 1988
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
No
7
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
Federal FCRA Summary of Rights Acknowledgment
By checking this box, I acknowledge that I
have read and understand the Summary of
Rights.
Yes
Disclosure Agreement
I agree with the above language Yes
Drug and Alcohol Release
I agree with the above language Yes
Certification Release
I agree with the above language Yes
PSP Release
I agree with the above language Yes
User Requested Copy
User requested a copy to be sent to this
email address adwl4d@r.postjobfree.com.
Yes
By my check of this box, I represent that I
understand and agree to the above and
that I intend to execute this document by
electronic signature in checking this box.
Yes
8
Signature
Full Name Raymond Edwin Gilson
IP Address 65.8.51.217
Signature Date/Time 02-08-2017 3:28 PM
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: 02-08-2017 3:28 PM
Signed:
9
CONSUMER DISCLOSURE AND AUTHORIZATION FORM
Disclosure Regarding Background Investigation
Logiflex Inc (the "Company") may request, for lawful employment purposes, background information about you from a consumer reporting agency in connection with your employment or application for employment (including independent contractor assignments, as applicable). This background information may be obtained in the form of consumer reports and/or investigative consumer reports
(commonly known as "background reports"). These background reports may be obtained at any time after receipt of your authorization and, if you are hired or engaged by the Company, throughout your employment or your contract period. HireRight, LLC, or another consumer reporting agency, will prepare or assemble the background reports for the Company. HireRight, LLC is located and can be contacted by mail at 3349 Michelson Dr. Suite 150, Irvine, CA 92612, and HireRight can be contacted by phone at 800-***-****. Information about HireRight's privacy practices is available at www.hireright.com/Privacy-Policy.aspx. The background report may contain information concerning your character, general reputation, personal characteristics, mode of living, and credit standing. The types of information that may be obtained include, but are not limited to: social security number verifications; address history; credit reports and history; criminal records and history; public court records; driving records; accident history; worker's compensation claims; bankruptcy filings; educational history verifications (e.g., dates of attendance, degrees obtained); employment history verifications (e.g., dates of employment, salary information, reasons for termination, etc.); personal and professional references checks; professional licensing and certification checks; drug/alcohol testing results, and drug/alcohol history in violation of law and/or company policy; and other information bearing on your character, general reputation, personal characteristics, mode of living and credit standing.
This information may be obtained from private and public record sources, including, as appropriate: government agencies and courthouses; educational institutions; former employers; personal interviews with sources such as neighbors, friends and associates; and other information sources. If the Company should obtain information bearing on your credit worthiness, credit standing or credit capacity for reasons other than as required by law, then the Company will use such credit information to evaluate whether you would present an unacceptable risk of theft or other dishonest behavior in the job for which you are being evaluated. You may request more information about the nature and scope of any investigative consumer reports by contacting the Company. Printed Name:
Raymond Edwin Gilson
Social Security #:
8241
Signed Date: 02-08-2017
Raymond Edwin Gilson
9230 44ave
9230 44ave
Sebastian, FL 32958
Gender:
10
Authorization of Background Investigation
I have carefully read and understand this Disclosure and Authorization form and the attached summary of rights under the Fair Credit Reporting Act. By my signature below, I consent to preparation of background reports by a consumer reporting agency such as HireRight, LLC, and to the release of such background reports to the Company and its designated representatives and agents, for the purpose of assisting the Company in making a determination as to my eligibility for employment (including independent contractor assignments, as applicable), promotion, retention or for other lawful employment purposes. I understand that if the Company hires me or contracts for my services, my consent will apply, and the Company may obtain background reports, throughout my employment or contract period.
I understand that information contained in my employment or contractor application, or otherwise disclosed by me before or during my employment or contract assignment, if any, may be used for the purpose of obtaining and evaluating background reports on me. I also understand that nothing herein shall be construed as an offer of employment or contract for services. I hereby authorize law enforcement agencies, learning institutions (including public and private schools and universities), information service bureaus, credit bureaus, record/data repositories, courts (federal, state and local), motor vehicle records agencies, my past or present employers, the military, and other individuals and sources to furnish any and all information on me that is requested by the consumer reporting agency.
By my signature below, I also certify the information I provided on and in connection with this form is true, accurate and complete. I agree that this form in original, faxed, photocopied or electronic (including electronically signed) form, will be valid for any background reports that may be requested by or on behalf of the Company. Printed Name:
Raymond Edwin Gilson
Social Security #:
8241
Signed Date: 02-08-2017
Raymond Edwin Gilson
9230 44ave
9230 44ave
Sebastian, FL 32958
Gender:
11
IMPORTANT DISCLOSURE
REGARDING BACKGROUND REPORTS FROM THE PSP Online Service In connection with your application for employment with Logiflex 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 Logiflex 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. 12
Printed Name:
Raymond Edwin Gilson
Signed Date: 02-08-2017
13
Additional State Law Notices
If you are a California, Maine, Massachusetts, New York or Washington State applicant, employee or contractor, please also note: CALIFORNIA: Pursuant to section 1786.22 of the California Civil Code, you may view the file maintained on you by HireRight during normal business hours. You may also obtain a copy of this file, upon submitting proper identification and paying the actual copying costs, by appearing at HireRight's offices in person, during normal business hours and on reasonable notice, or by certified mail. You may also receive a summary of the file by telephone, upon submitting proper identification and written request. HireRight has trained personnel available to explain your file to you, including any coded information, and will provide a written explanation of any coded information contained in your file. If you appear in person, you may be accompanied by one other person, provided that person furnishes proper identification. "Proper identification" includes documents such as a valid driver's license, social security account number, military identification card, and credit cards. If you cannot identify yourself with such information, HireRight may require additional information concerning your employment and personal or family history to verify your identity. MAINE: You have the right, upon request, to be informed of whether an investigative consumer report was requested, and if one was requested, the name and address of the consumer reporting agency furnishing the report. You may request and receive from the Company, within five business days of our receipt of your request, the name, address and telephone number of the nearest unit designated to handle inquiries for the consumer reporting agency issuing an investigative consumer report concerning you. You also have the right, under Maine law, to request and promptly receive from all such agencies copies of any such reports. MASSACHUSETTS: If we request an investigative consumer report, you have the right, upon written request, to a copy of the report. NEW YORK: You have the right, upon written request, to be informed of whether or not an investigative consumer report was requested. If an investigative consumer report is requested, you will be provided with the name and address of the consumer reporting agency furnishing the report. You may inspect and receive a copy of the report by contacting that agency. Please see https://www.HireRight.com/NY_Article_23_A.pdf?enable_url=true for additional information about New York law, as applicable. WASHINGTON STATE: If the Company requests an investigative consumer report, you have the right, upon written request made within a reasonable period of time after your receipt of this disclosure, to receive from the Company a complete and accurate disclosure of the nature and scope of the investigation requested by the Company. You also have the right to request from the consumer reporting agency a written summary of your rights and remedies under the Washington Fair Credit Reporting Act. Printed Name: Raymond Edwin Gilson
Social Security #: 8241
Signed Date: 02-08-2017
Signed:
14
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 02-08-2017
Date
X 8241
Social Security Number
Raymond Edwin Gilson
9230 44ave
9230 44ave
Sebastian, FL 32958
Gender:
X Raymond Edwin Gilson
Print Name (First, MI, Last)
X
Signature
I, the above mentioned signer, hereby authorize Empire 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 Logiflex Inc
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 Logiflex Inc, or to HireRight for the sole purpose of transmitting such records to Logiflex 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 Logiflex Inc or HireRight to review involves tests required by DOT. If any carrier
(company/school) listed above furnishes Logiflex 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.
15
CONSUMER DISCLOSURE AND AUTHORIZATION FORM
Disclosure Regarding Background Investigation
Logiflex Inc (the "Company") may request, for lawful employment purposes, background information about you from a consumer reporting agency in connection with your employment or application for employment (including independent contractor assignments, as applicable). This background information may be obtained in the form of consumer reports and/or investigative consumer reports
(commonly known as "background reports"). These background reports may be obtained at any time after receipt of your authorization and, if you are hired or engaged by the Company, throughout your employment or your contract period. HireRight, LLC, or another consumer reporting agency, will prepare or assemble the background reports for the Company. HireRight, LLC is located and can be contacted by mail at 3349 Michelson Dr. Suite 150, Irvine, CA 92612, and HireRight can be contacted by phone at 800-***-****. Information about HireRight's privacy practices is available at www.hireright.com/Privacy-Policy.aspx. The background report may contain information concerning your character, general reputation, personal characteristics, mode of living, and credit standing. The types of information that may be obtained include, but are not limited to: social security number verifications; address history; credit reports and history; criminal records and history; public court records; driving records; accident history; worker's compensation claims; bankruptcy filings; educational history verifications (e.g., dates of attendance, degrees obtained); employment history verifications (e.g., dates of employment, salary information, reasons for termination, etc.); personal and professional references checks; professional licensing and certification checks; drug/alcohol testing results, and drug/alcohol history in violation of law and/or company policy; and other information bearing on your character, general reputation, personal characteristics, mode of living and credit standing.
This information may be obtained from private and public record sources, including, as appropriate: government agencies and courthouses; educational institutions; former employers; personal interviews with sources such as neighbors, friends and associates; and other information sources. If the Company should obtain information bearing on your credit worthiness, credit standing or credit capacity for reasons other than as required by law, then the Company will use such credit information to evaluate whether you would present an unacceptable risk of theft or other dishonest behavior in the job for which you are being evaluated. You may request more information about the nature and scope of any investigative consumer reports by contacting the Company. Employer / Contractor / Educational Institution:
Land Span
Printed Name:
Raymond Edwin Gilson
Social Security #:
8241
Signed Date: 02-08-2017
Raymond Edwin Gilson
9230 44ave
9230 44ave
Sebastian, FL 32958
Gender:
16
Authorization of Background Investigation
I have carefully read and understand this Disclosure and Authorization form and the attached summary of rights under the Fair Credit Reporting Act. By my signature below, I consent to preparation of background reports by a consumer reporting agency such as HireRight, LLC, and to the release of such background reports to the Company and its designated representatives and agents, for the purpose of assisting the Company in making a determination as to my eligibility for employment (including independent contractor assignments, as applicable), promotion, retention or for other lawful employment purposes. I understand that if the Company hires me or contracts for my services, my consent will apply, and the Company may obtain background reports, throughout my employment or contract period.
I understand that information contained in my employment