A Driver Truck
Resume:
Tenstreet *
Tulsa, OK *****
**-**-**** *:31:50PM CDT
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Thank you for your interest in Tenstreet2. To request a contracting position, please complete our online questionnaire for contract. Incomplete information will delay the processing of your questionnaire or prevent it from being submitted. Not ready to complete a full application?Submit a Pre-application Inquiry by clicking here Thank you for your interest in Tenstreet2. To apply for a driving position, please complete our online application for lease contract or driver qualification. 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.
Make sure you are entering your name exactly as it appears on your CDL! Active Jobs
Job Name OTR Driver From Coast to Coast
Job Title OTR Driver From Coast to Coast
Personal Information
Referral Code: jp_indeed_smt
Name William Bob Green
Residence 4 years or longer (If No,
previous addresses shown below)
Yes
Current Address 107 Andrew Jackson Court
City, State/Province Zip/Postal Buena Vista, GA 31803 Country United States
SSN/SIN 1383
Date of Birth
Primary Phone 229-***-****
Preferred method of contact Cell Phone
Best time to contact you Any
Email adwzo5@r.postjobfree.com
1
Licenses
License Number 443
Licensing Authority GA
Country United States
License Class Class A
License Expiration Date 09-28-2025
Current License Yes
Commercial Driver License Yes
Restrictions
No Night Driving No
Corrective Lenses No
No Air Brakes No
No Manual Transmission No
Other Restriction No
Employment / Unemployment
Atrix Trucking Corp
Company Atrix Trucking Corp
Start Date 05-2023
End Date 05-2023
Address 130 Birchwood Drive
City, State/Province Zip/Postal Maitland, FL 32751 Country United States
Phone 407-***-****
Fax 888-***-****
Position Held Truck driver
Reason for leaving? Still here
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
Yes
2
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?
Yes
Areas Driven Southeast
Miles driven weekly 2000-2500
Pay Range (cents/mile)
Most common truck driven Conventional Tractor
Most common trailer Van
Trailer length 53 feet or more
Green Trucking Llc
Company Green Trucking Llc
Start Date 03-2023
End Date 04-2023
Address 107 Andrew Jackson Court
City, State/Province Zip/Postal Columbus, OH 31803 Country United States
Phone 229-***-****
Position Held Driver
Reason for leaving? Sold equipment
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?
No
Did you perform any safety sensitive
functions in this job, regulated by DOT,
and subject to drug and alcohol testing?
No
Areas Driven Southeast
Miles driven weekly 2500-3000
Pay Range (cents/mile)
Most common truck driven Conventional Tractor
3
Most common trailer Van
Trailer length 53 feet or more
Atrix Trucking Corp
Company Atrix Trucking Corp
Start Date 06-2016
End Date 02-2023
Address 130 Birchwood Drive
City, State/Province Zip/Postal Maitland, FL 32751 Country United States
Phone 407-***-****
Fax 888-***-****
Position Held Driver
Reason for leaving? Still working here
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 All 48
Miles driven weekly
Pay Range (cents/mile)
Most common truck driven Conventional Tractor
Most common trailer Van
Trailer length 53 feet or more
Ups
Company Ups
Start Date 06-2016
End Date 06-2020
Address 55 Glenlake Parkway, NE
4
City, State/Province Zip/Postal Atlanta, GA 30328
Country United States
Phone 888-***-****
Fax 877-***-****
Position Held Contracted Driver
Reason for leaving? Still Employed
Were you terminated/discharged/laid off? No
Is this your current employer? Yes
May we contact this employer at this time? Yes
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
Miles driven weekly
Pay Range (cents/mile)
Most common truck driven Conventional Tractor
Most common trailer Container
Trailer length 53 feet or more
Summit
Company Summit
Start Date 02-2016
End Date 06-2016
Address 6901 chicago avenue
City, State/Province Zip/Postal Gary, IN 46406
Country United States
Phone 219-***-****
Position Held Contracted Driver
Reason for leaving? Slow Freight
Were you terminated/discharged/laid off? No
Is this your current employer? No
5
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
Miles driven weekly
Pay Range (cents/mile)
Most common truck driven Conventional Tractor
Most common trailer Container
Trailer length 53 feet or more
Green Trucking
Company Green Trucking
Start Date 05-1986
End Date 05-2016
Address 107 Andrew Jackson Court
City, State/Province Zip/Postal Buena Vista, GA 31803 Country United States
Phone 229-***-****
Position Held Driver
Reason for leaving? Sold equipment
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?
No
Did you perform any safety sensitive
functions in this job, regulated by DOT,
No
6
and subject to drug and alcohol testing?
Areas Driven Southeast
Miles driven weekly
Pay Range (cents/mile)
Most common truck driven Conventional Tractor
Most common trailer Van
Trailer length 53 feet or more
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
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
7
Vehicle Accident Record
Please list all accidents for the last 12.5 years
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? 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 William Bob Green
IP Address 2600:1005:b18f:9
Signature Date/Time 05-04-2023 9:31 PM
By clicking next, I agree that my electronic signature will be applied to my application. 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. 8
Signed Date: 05-04-2023 9:31 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
California Notice Regarding Background Investigation Acknowledgment By checking the box, I 1) agree to use an
electronic signature to demonstrate my
consent, 2) agree that an electronic
signature is as legally binding as an ink
signature, and 3) acknowledge that I have
read and understood this California
Disclosure Regarding Background Checks
document.
Yes
Massachusetts Criminal Policy and Record Correction Acknowledgment By checking the box, I (a) acknowledge
that I have read and understand the
Company?s Massachusetts Criminal
Record Policy and Information Concerning
the Process in Correcting a Criminal
record and have also been given the
opportunity copy/print both, and (b) agree
to use an electronic signature to
demonstrate my consent. An electronic
signature is as legally binding as an ink
signature.
Yes
New Jersey Summary of Rights Acknowledgment
By checking the box, I (a) acknowledge
that I have read and understand the
Summary of Rights Under New Jersey's
Fair Credit Reporting Act and also have
Yes
9
been given the opportunity to copy/print
the Summary of Rights, and (b) agree to
use an electronic signature to demonstrate
my acknowledgment. An electronic
signature is as legally binding as an ink
signature.
New York State Article 23-A Notice
By checking the box, I (a) acknowledge
that I have read and understand the New
York State Correction Law Article 23-A and
have been given the opportunity to
copy/print it and (b) agree to use an
electronic signature to demonstrate my
acknowledgment. An electronic signature
is as legally binding as an ink signature.
Yes
Washington Summary of Rights Acknowledgment
By checking this box, I acknowledge that I
have read and understood the above State
of Washington Summary of Consumer
Rights
Yes
San Francisco Fair Chance Ordinance Acknowledgment By checking the box, I (a) acknowledge
that I have read and understand the San
Francisco Fair Chance Ordinance and also
have been given the opportunity to
copy/print the ordinance, and (b) agree to
use an electronic signature to demonstrate
my acknowledgment. An electronic
signature is as legally binding as an ink
signature.
Yes
Notice to Applicants of Rights Under Section 615(a)(3). NOTICE TO APPLICANTS OF RIGHTS
UNDER Sec. 615(a)(3) OF THE FAIR
CREDIT
REPORTING ACT (15 U.S.C. Sec.
1681m)
To the extent you applied for a driving
position with Swift Transportation by mail,
telephone, facsimile, e-mail, computer, via
Yes
10
the internet, or other similar means, you
are hereby provided with notice of the
following:
(A) The name, address and
toll-free telephone number
of the consumer reporting
agency that furnished Swift
with the report. That
consumer reporting agency
is:
Hire Right
5151
California
Ave.
Irvine, CA
92617
(B) To the extent that any
adverse action might be
taken based in whole or in
part onany consumer
report, the above listed
consumer reporting agency
did not or will not make the
decision to take the adverse
action and cannot or will not
be able to provide you with
the specific reasons why
the adverse action was or
will be taken.
(C) Your right to obtain,
under section 612 [Sec.
1681j], a free copy of your
consumer report from the
consumer reporting agency
identified above, not later
than 60 days from receipt of
this notice and/or any notice
of an adverse action.
(D) Your right to dispute,
under section 611 [Sec.
1681i], with a consumer
reporting agency the
accuracy or completeness
of any information in a
consumer report furnished
by the agency.
11
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
electronic signature to demonstrate my
consent. An electronic signature is as
legally binding as an ink signature.
Yes
FCRA Disclosure
I agree to the above disclosure text 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
Clearinghouse Release
By checking the box, I (a) acknowledge
that I have read and understand the above
Yes
12
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.
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
Custom Release 1
I agree to the above language Yes
Consent to Release Testing
I agree to the above language Yes
User Requested Copy
User requested a copy to be sent to this
email address adwzo5@r.postjobfree.com.
Yes
13
Disclosure Agreement
This is a disclosure agreement. You read it and sign it before the actual release. Printed Name:
William Bob Green
Social Security #:
1383
Signed Date: 05-04-2023
William Bob Green
107 Andrew Jackson Court
Buena Vista, GA 31803
Gender:
14
GENERAL DISCLOSURES:
I acknowledge that I will be required and agree to submit to a physical examination and related medical evaluation, and controlled substance and alcohol use testing which may be performed by Schneider and/or Schneider's designated employees and/or third party agents, and I authorize release of my results and all prior medical records to Schneider and its designated employees and/or third party agents (including medical examiners), as part of Schneider's evaluation procedures in deciding whether I should be offered or continued in employment/lease. If I am offered employment and/or continue in my employment/lease, I authorize the release of my Department of Transportation required physical examination to applicable governmental agencies (e.g., the state Department of Motor Vehicles) if necessary to maintain compliance with local, state, and federal laws regarding the maintenance of a commercial driver's license.
I understand that in order to investigate applicant safety employment history per FMCSA regulations, Schneider must investigate the information applicants have provided by contacting DOT regulated employers/lessors from the past 3 years. Applicants have the following rights pursuant to FMCSA Reg 391.23 (i) (1): a) The right to review investigative information provided by previous DOT employers/lessors for the preceding three years by submitting a written request to Schneider, ATTN: Regulatory Dept. within 30 days after being employed/leased or of being notified of denial of employment/lease. b) The right to have errors in the information corrected by applicants previous employer/lessor and for that previous employer/lessor to re-send the corrected information to Schneider and the right to have a rebuttal statement attached to the alleged erroneous information if the previous employer/lessor and the applicant cannot agree on the accuracy of the information.
By completing, submitting and signing this application, I hereby agree to all of the above. I certify by my signature that all entries and information on and in this application and all supplemental documents are true and complete to the best of my knowledge. I agree that not updating, or providing false, misleading or incomplete statements or data in this application and/or supplemental documents is grounds for immediate termination of my employment/lease, regardless of when such information is discovered. I understand that my signing of this authorization does not guarantee me a job/lease with Schneider. Printed Name:
William Bob Green
Social Security #:
1383
Signed Date: 05-04-2023
William Bob Green
107 Andrew Jackson Court
Buena Vista, GA 31803
Gender:
15
IMPORTANT DISCLOSURE
REGARDING BACKGROUND REPORTS FROM THE PSP Online Service In connection with your application for employment with Tenstreet 2 ("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 Tenstreet 2 ("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:
William Bob Green
Signed Date: 05-04-2023
16
Consent for Limited Queries of the Federal Motor Carrier Safety Administration (FMCSA) Drug and Alcohol Clearinghouse
I hereby provide consent to Tenstreet 2 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 Tenstreet 2 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 Tenstreet 2 to conduct a limited query of the Clearinghouse, Tenstreet 2 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 Tenstreet 2 indicates that drug or alcohol information exists about me in the Clearinghouse, the FMCSA will not disclose that information to Tenstreet 2 unless I give additional specific consent within the Clearinghouse. However, I understand that Tenstreet 2 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. 05-04-2023
William Bob Green Date
17
INVESTIGATIVE INFORMATION AND CONSUMER REPORTING RIGHTS FAIR CREDIT REPORTING ACT DISCLOSURE
In connection with your application for employment/lease, Schneider may obtain Consumer Reports and/or Investigative Consumer Reports regarding your character, general reputation, mode of living, motor vehicle record, criminal background record and/or other appropriate public record information from a Consumer Reporting Agency, as those terms are defined in the Fair Credit Reporting Act and amendments ("FCRA"). These reports may also include the names and dates of your previous employer/lessor, reasons for the termination of your prior employment/lease, work experience and any other type of information authorized under the FCRA or other applicable laws. Such reports may come from federal, state, local and/or any other agencies which contain and/or maintain such records. You may request in writing a complete disclosure of the nature and scope of the investigation to be performed. A Summary of Your Rights under the Fair Credit Reporting Act and Article 23-A NY Correction Law can be obtained at www.schneiderjobs.com or from your Recruiter.
Fair Credit Reporting Act Authorization
I hereby authorize Schneider to obtain Consumer Reports and/or Investigative Consumer Reports from any appropriate Consumer Reporting Agency and understand that such Consumer Reports and/or Investigative Consumer Reports may be used by Schneider in the determination of whether or not to offer me employment/lease. I understand that I have the right to make a request of such Consumer Reporting Agencies, upon proper identification, of the nature and substance of all information in such files on me, including the source of information and recipients of any reports on me which have been previously furnished by the Consumer Reporting Agencies within the two year period preceding my request. I therefore authorize the procurement of said Consumer Reports and/or Investigative Consumer Reports by Schneider and, if hired/leased, understand that this authorization shall remain on file and shall serve as on-going authorization for Schneider to procure additional Consumer Reports on at least an annual basis, or at any other time during my employment/lease.
For California, Oklahoma, and Minnesota Residents Only: You can request a free copy of your Consumer Report(s) ordered from HireRight by calling their toll free number (1-800-***-****) or writing to: HireRight Marketing, S. 129th E Avenue, Suite 200, Tulsa, OK 74134. You may also dispute the accuracy or completeness of any information in the Consumer Report(s) with HireRight. Printed Name: William Bob Green
Social Security #: 1383
Signed Date: 05-04-2023
Signed:
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 05-04-2023
Date
X 1383
Social Security Number
William Bob Green
107 Andrew Jackson Court
Buena Vista, GA 31803
Gender:
X William Bob Green
Print Name (First, MI, Last)
X
Signature
I, the above mentioned signer, hereby authorize Atrix Trucking Corp To release and forward in accordance with the following regulation, all known information pertaining to my alcohol and controlled substances testing/
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