Class A Commercial Motor
Resume:
DLM
PO Box ***
Fairview Village, PA *****
**-**-**** **:36:49PM CDT
IntelliApp
Thank you for your interest in DLM. 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 Ryan Keith Page, Sr.
Current Address 239 S Cook Ave
City, State/Province Zip/Postal Trenton, NJ 08629
Country United States
Residence 3 years or longer (If No,
previous addresses shown below)
Yes
SSN/SIN 7707
Date of Birth
Primary Phone 609-***-****
Cell Phone 609-***-****
Email adx55z@r.postjobfree.com
Company Questions
GENERAL INFORMATION
What position are you applying for? Company Driver What Date can you Start? 07-10-2023
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? 07-05-2023 Do you read, write, and speak English? Yes
Have you ever worked for this company
before?
Yes
1
Enter start and end dates, location,
position, and reason for leaving:
2019 temporary to permanent
Have you ever been known by any other
name?
No
Enter name:
How did you hear about us? Other
If "Driver Referral", please enter the
driver's name
If "Other", please explain Work here before
Emergency Contact: Please list name
Relationship and Contact Information.
Terricka L Page/wife
609-***-**** home
609-***-**** cell
DRIVING EXPERIENCE
Class A or B? Class A
For each class of equipment, select years of experience. If no experience in a class, select "None".
Straight Truck 5-6 years
Tractor and Semi-Trailer 10+ years
Tractor - Two Trailers 4-5 years
Moffett Experience No
How many Years?
How many Months?
Do you have a TWIC Card? Yes
Expiration Date: 02-28-2027
Licenses
License Number 681
Licensing Authority NJ
Country US
License Class Class A
License Expiration Date 02-28-2026
Physical Expiration Date 08-12-2023
Current License Yes
Commercial Driver License Yes
Endorsements
Tanker Endorsement Yes
2
HAZMAT Endorsement Yes
X Endorsement No
Doubles Triples Endorsement Yes
Other Endorsement No
Employment / Unemployment
GG4 Trucking Company
Company GG4 Trucking Company
Start Date 02-2023
End Date 07-2023
Address
City, State/Province Zip/Postal Trenton, NJ 08638 Country United States
Phone 609-***-****
Position Held Driver
Reason for leaving? Business restructure the guy down Baltimore
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 NJ, PA, DE
Miles driven weekly 500-1000
Most common truck driven Tractor-Trailer
Most common trailer Container
Trailer length 53 feet or more
Centerline Drivers
Company Centerline Drivers
3
Start Date 09-2022
End Date 01-2023
Address
City, State/Province Zip/Postal Santa Ana, CA
Country United States
Phone 714-***-****
Fax 714-***-****
Position Held Leased CDL A DRIVER
Reason for leaving? Consistent work/Temp Service
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 NJ
Miles driven weekly 500-1000
Most common truck driven Day Cab Conventional
Most common trailer Van
Trailer length 45 to 52 feet
Unemployment
Start Date 08-2022
End Date 09-2022
Comment Unemployed seeking employment
Load Solutions USA Inc
Company Load Solutions USA Inc
Start Date 02-2022
End Date 07-2022
Address 2121 Lockport Rd
City, State/Province Zip/Postal Niagara Falls, NY 14304 4
Country United States
Phone 201-***-****
Position Held Class A Driver
Reason for leaving? Lay-off
Were you terminated/discharged/laid off? Yes
Termination Explanation Company is restructuring temporary layoff may or may not open back
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 North Jersey
Miles driven weekly 1000-1500
Most common truck driven Tractor-Trailer
Most common trailer Van
Trailer length 53 feet or more
Edison Freight
Company Edison Freight
Start Date 11-2021
End Date 02-2022
Address 4111 18th Ave
City, State/Province Zip/Postal New York, NY 11218 Country United States
Phone 347-***-****
Position Held CDL A Driver
Reason for leaving? Resign
Were you terminated/discharged/laid off? No
Is this your current employer? No
May we contact this employer at this time? Yes
5
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 NY, NYC, NJ
Miles driven weekly 1500-2000
Most common truck driven Tractor - Trailer
Most common trailer Van
Trailer length 53 feet or more
Spiniello Co
Company Spiniello Co
Start Date 05-2020
End Date 10-2021
Address 109 Flock Rd
City, State/Province Zip/Postal Livingston, NJ 08690 Country United States
Phone 973-***-****
Position Held Class A Driver
Reason for leaving? Lay-off
Were you terminated/discharged/laid off? Yes
Termination Explanation Lay-off
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
6
Areas Driven local
Miles driven weekly 1000-1500
Most common truck driven Tractor-Trailer
Most common trailer Flatbed
Trailer length 32 to 44 feet
Unemployment
Start Date 10-2019
End Date 04-2020
Comment
Driver Leasing Management
Company Driver Leasing Management
Start Date 03-2018
End Date 09-2019
Address 2525 W Main St
City, State/Province Zip/Postal Norristown, PA 19403 Country United States
Phone 610-***-****
Position Held Class A Driver
Reason for leaving? Temporary driver
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 local
Miles driven weekly 1000-1500
Most common truck driven Day Cab
Most common trailer Flatbed
Trailer length 45 to 52 feet
7
All County Recycle Inc
Company All County Recycle Inc
Start Date 03-2018
End Date 12-2018
Address 391 Enterprise Ave
City, State/Province Zip/Postal Trenton, NJ 08638 Country United States
Phone 609-***-****
Position Held Class A Driver
Reason for leaving? Resign/Equipment unsafe, failure to make repairs
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 local
Miles driven weekly 500-1000
Most common truck driven Tractor-Trailer
Most common trailer Van
Trailer length 45 to 52 feet
Unemployment
Start Date 12-2017
End Date 02-2018
Comment
Estes Express Lines
Company Estes Express Lines
Start Date 02-2015
End Date 11-2017
8
Address 4095 Blanche Rd
City, State/Province Zip/Postal Bensalem, PA 19020 Country United States
Phone 804-***-****
Fax 804-***-****
Position Held Class A Driver
Reason for leaving? Lay-off/low seniority, work slow 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 local
Miles driven weekly 500-1000
Most common truck driven Day Cab
Most common trailer Liftgate
Trailer length 45 to 52 feet
Unemployment
Start Date 04-2014
End Date 01-2015
Comment
Driver Leasing Management
Company Driver Leasing Management
Start Date 01-2009
End Date 03-2014
Address 2525 W Main St
City, State/Province Zip/Postal Norristown, PA 19403 Country United States
Phone 609-***-****
9
Position Held Class A Driver
Reason for leaving? Temp-permanent position/hire by Estes 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 local
Miles driven weekly 1500-2000
Most common truck driven Day Cab
Most common trailer Van
Trailer length 45 to 52 feet
Fundamental Labor Strategies, Inc
Company Fundamental Labor Strategies, Inc
Start Date 09-2013
End Date 03-2014
Address 58 W Bridge St
City, State/Province Zip/Postal New Hope, PA 18938 Country United States
Phone 215-***-****
Fax 215-***-****
Position Held Class B Tanker
Reason for leaving? SeasonalPosition/Home Oil Delivery 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
10
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 South Jersey
Miles driven weekly 500-1000
Most common truck driven Class B Vehicle
Most common trailer Tank Trailer
Trailer length 31 feet or less
Trucking School
Start Date 02-1992
End Date 04-1992
School Shore Tractor Trailer
Address
Address 2
City, State/Province Highstown, NJ
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 4
Hours of Instruction 100
Border Crossing No
Log Books Yes
Federal Motor Carrier Regulations Yes
Hazardous Materials No
11
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)]
No
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
12
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
Signature
Full Name Ryan Keith Page, Sr.
IP Address 2600:4040:a070:f
Signature Date/Time 07-07-2023 10:36 PM
By signing my application below, I agree to use an electronic signature to demonstrate my consent. An electronic signature is as legally binding as an ink signature. This certifies that this application was completed by me, and that all entries on it and information in it are true and complete to the best of my knowledge.
Signed Date: 07-07-2023 10:36 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
13
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
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.
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
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
Yes
14
electronic signature to demonstrate my
consent. An electronic signature is as
legally binding as an ink signature.
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 adx55z@r.postjobfree.com.
Yes
15
DISCLOSURE FOR CONSUMER REPORTS
In connection with your employment or owner-operator (independent contractor) application, DLM 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:
Ryan Keith Page, Sr.
Social Security #:
7707
Signed Date: 07-07-2023
Ryan Keith Page, Sr.
239 S Cook Ave
Trenton, NJ 08629
Gender:
16
AUTHORIZATION FOR CONSUMER REPORTS
I authorize DLM 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:
Ryan Keith Page, Sr.
Social Security #:
7707
Signed Date: 07-07-2023
Ryan Keith Page, Sr.
239 S Cook Ave
Trenton, NJ 08629
Gender:
17
IMPORTANT DISCLOSURE
REGARDING BACKGROUND REPORTS FROM THE PSP Online Service In connection with your application for employment with DLM ("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 DLM ("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:
Ryan Keith Page, Sr.
Signed Date: 07-07-2023
18
Consent for Limited Queries of the Federal Motor Carrier Safety Administration (FMCSA) Drug and Alcohol Clearinghouse
I hereby provide consent to DLM 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 DLM 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 DLM to conduct a limited query of the Clearinghouse, DLM 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 DLM indicates that drug or alcohol information exists about me in the Clearinghouse, the FMCSA will not disclose that information to DLM unless I give additional specific consent within the Clearinghouse. However, I understand that DLM 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. 07-07-2023
Ryan Keith Page, Sr. Date
19
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 07-07-2023
Date
X 7707
Social Security Number
Ryan Keith Page, Sr.
239 S Cook Ave
Trenton, NJ 08629
Gender:
X Ryan Keith Page, Sr.
Print Name (First, MI, Last)
X
Signature
I, the above mentioned signer, hereby authorize GG4 Trucking Company To release and forward in accordance with the following regulation, all known information pertaining to my alcohol and controlled substances testing/training records to DLM
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 DLM ("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
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