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Click here or scroll down to respond to this candidateCandidate's Name
Street Address NW 56th StreetLincoln, NE Street Address
PHONE NUMBER AVAILABLEStreet Address -23-2023 7:33:53PM CDTIntelliAppThank you for your interest in Candidate's Name . To apply for a driving position, please complete our online application for 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.Personal InformationReferral Code: Homepage-HerolinkName Vance Columbus FitzgeraldResidence 5 years or longer (If No,previous addresses shown below)NoCurrent Address 1714 Pace Road Ext Lot 10City, State/Province Zip/Postal Pocahontas, AR 72455 Country United StatesAddresses Over last 5 years Address 11714 PACE RD. EXT LOT 10POCAHONTAS, AR 72455United States06-2022 to 10-2023Address 21052 CR 139CORNING, AR 72422United States10-2020 to 06-2022Address 31303 N PARK STPocahontas, AR 72455United States11-2017 to 10-2020SSN/SIN 1944Date of BirthPrimary Phone PHONE NUMBER AVAILABLEPreferred method of contact Text MessageBest time to contact you Night1Email EMAIL AVAILABLEYes, I agree to receive informationconcerning future opportunities orpromotions from Candidate's Name
by email or other commercial electroniccommunications.YesWould you like to receive communicationfrom Candidate's Name via textmessage?By participating, you consent to receivetext messages sent by an automatictelephone dialing system, which maycontain recruiting/advertising messages.Consent to these terms is not a conditionof being hired, contracted, or leased. Youmay opt out at any time by texting STOP tounsubscribe. You also agree that CreteCarrier Corporation's service providerreceives in real time and logs your textmessages with Candidate's Name .YesCompany QuestionsGENERAL INFORMATIONAre you applying as a Company Driver? YesAre you applying as an Owner Operator? NoPlease enter your business name, phonenumber, address, city, state, and zipAre you applying as a Driver for an OwnerOperator?NoPlease enter the name of the business youare driving for, the business phonenumber, address, city, state, and zipAre you applying as a Student Driver? NoIf you are a resident alien, please give youralien number from your Resident AlienCare, Form I-551Are you legally eligible for employment inthe United States?YesAre you currently employed? NoWhat date did your last employment end? 10/2023Do you read, write, and speak English? YesHave you ever worked for this companybefore?No2Which company?Do you have a current TWIC card? NoExpiration date:Have you held a drivers license in anyother name within the last ten(10) years? Ifyes, please provide the other name(s):NoOther First Name 1:Other Last Name 1:Other First Name 2:Other Last Name 2:Other First Name 3:Other Last Name 3:Other First Name 4:Other Last Name 4:Were you referred by a Crete/Shaffer/Huntdriver?NoEnter the driver's first nameEnter the driver's last nameEnter the driver's driver code (if known)How did you hear about us? TruckDriversNowIf "Other", please describeDo you hold any safe driving awards? NoWhat were they and with whom did youearn them?In case of Emergency, notify:Name: Kerticia PettersonAddress: 1052 CR 139City: CORNINGState: ARZip: 72422Phone Number: PHONE NUMBER AVAILABLEDOT QUESTIONNAIREA. Have you ever been denied a license,permit or privilege to operate a motorvehicle?NoDate of Denial:3City:State:Details:If you have a second or subsequent denial,please enter the details here:B. Has your motor vehicle operator'slicense, permit or privilege ever beensuspended or revoked?NoDate of Suspension or Revocation:City:State:Details:If you have a second or subsequentsuspension or revocation, please enter thedetails here:C. Have you ever been disqualified fromdriving a motor vehicle under the D.O.T.regulations?NoDate of Disqualification:City:State:Details:If you have a second or subsequentdisqualification, please enter the detailshere:D. Are you currently able to obtain ahazardous material endorsement on yourcommercial drivers license?YesE. Regarding DOT Drug and Alcohol regulations, have you, within the last three (3) years preceding the date of this application:1. Undergone an alcohol test in which aconcentration of 0.04 or greater has beenindicated?NoDate of Test:City:State:Details:If you have a second or subsequent test,please enter the details here:No42. Undergone a controlled substance testin which a positive result has beenverified?Date of Test:City:State:Details:If you have a second or subsequentpositive test, please enter the details here:3. Refused to undergo either an alcohol ordrug test or adulterated or substituted atest specimen for a controlled substance?NoDate of Test:City:State:Details:If you have a second or subsequentrefused, adulterated, or substituted test,please enter the details here:4. Refused to submit to a post-accident,random, reasonable suspicion, or follow-upalcohol or controlled substance test?NoDate of Test:City:State:Details:If you have a second or subsequentrefused test,please enter the details here:5. Tested positive, or refused to test, on apre-employment drug or alcohol test by anemployer to which you applied for, but didnot obtain, safety-sensitive transportationwork covered by DOT agency drug andalcohol testing rules.NoDate of Test:City:State:Details:If you have a second or subsequentpositive or refused test, please enter thedetails here:56. Committed any other violation of aFederal Motor Carrier SafetyAdministration drug or alcohol regulation?NoDate of Violation:City:State:Details:If you have a second or subsequentviolation, please enter the details here:If you answered "yes" to any of the six (6) questions above please answer question seven (7) below. If you answered "No" to the above E 1-6 questions, please answer"Non Applicable."7. Following any violation of a D.O.T. drugor alcohol regulation as indicated above,did you successfully complete the return towork requirements?Non ApplicableIf you answered "yes" to the questionabove, please explain:Driver Referral First NameDriver Referral Last NameDriver Referral Driver CodeGCLIDLicensesList ALL licenses you have held.License Number 361Licensing Authority ARCountry USLicense Class Class AOriginal Issue Date 04-18-2022License Expiration Date 10-09-2027DOT Medical Card Expiration Date 05-12-2024Current License YesCommercial Driver License YesEndorsements None6Employment / UnemploymentWIEDEMAN FARMSCompany WIEDEMAN FARMSStart Date 07-2023End Date 10-2023AddressCity, State/Province Zip/Postal Corning, AR 72422Country United StatesPhone PHONE NUMBER AVAILABLEPosition Held Truck DriverReason for leaving? GOT HARVEST DONEWere you terminated/discharged/laid off? YesTermination Explanation LAID OFFIs this your current employer? NoMay we contact this employer at this time? YesDid you operate a commercial motorvehicle?YesWere you subject to the Federal MotorCarrier or Transport Canada SafetyRegulations while employed/contracted bythis employer/contractor?YesDid you perform any safety sensitivefunctions in this job, regulated by DOT,and subject to drug and alcohol testing?NoAreas Driven CORNINGMiles driven weekly 0-500Most common truck driven Tractor-TrailerMost common trailer OtherTrailer length 45 to 52 feetALPINE CONSTRUCTION LLCCompany ALPINE CONSTRUCTION LLCStart Date 10-2022End Date 06-2023AddressCity, State/Province Zip/Postal Pocahontas, AR 72455 Country United States7PhonePosition Held Truck DriverReason for leaving? LET GOWere you terminated/discharged/laid off? YesTermination Explanation LET GOIs this your current employer? NoMay we contact this employer at this time? YesDid you operate a commercial motorvehicle?YesWere you subject to the Federal MotorCarrier or Transport Canada SafetyRegulations while employed/contracted bythis employer/contractor?YesDid you perform any safety sensitivefunctions in this job, regulated by DOT,and subject to drug and alcohol testing?YesAreas Driven POCAHONTAS 150 MILES RADIUSMiles driven weekly 1000-1500Most common truck driven Tractor-TrailerMost common trailer OtherTrailer length 45 to 52 feetW.B. RUSSELL TRANSPORT LLCCompany W.B. RUSSELL TRANSPORT LLCStart Date 06-2022End Date 10-2022AddressCity, State/Province Zip/Postal Piggott, ARCountry United StatesPhonePosition Held Truck DriverReason for leaving? LET GOWere you terminated/discharged/laid off? YesTermination Explanation DISCHARGEDIs this your current employer? NoMay we contact this employer at this time? Yes8Did you operate a commercial motorvehicle?YesWere you subject to the Federal MotorCarrier or Transport Canada SafetyRegulations while employed/contracted bythis employer/contractor?YesDid you perform any safety sensitivefunctions in this job, regulated by DOT,and subject to drug and alcohol testing?YesAreas Driven MISSOUR-ARKANASMiles driven weekly 1500-2000Most common truck driven Tractor-TrailerMost common trailer OtherTrailer length 32 to 44 feetWIEDEMAN FARMSCompany WIEDEMAN FARMSStart Date 11-2021End Date 05-2022Address 561 CR 131City, State/Province Zip/Postal Corning, AR 72422Country United StatesPhone PHONE NUMBER AVAILABLEPosition Held Truck DriverReason for leaving? FINISHED HARVESTWere you terminated/discharged/laid off? YesTermination Explanation LAID OFFIs this your current employer? NoMay we contact this employer at this time? YesDid you operate a commercial motorvehicle?YesWere you subject to the Federal MotorCarrier or Transport Canada SafetyRegulations while employed/contracted bythis employer/contractor?YesDid you perform any safety sensitivefunctions in this job, regulated by DOT,and subject to drug and alcohol testing?NoAreas Driven CORNING9Miles driven weekly 0-500Most common truck driven Tractor-TrailerMost common trailer OtherTrailer length 45 to 52 feetIBEW 1516Company IBEW 1516Start Date 07-1992End Date 10-2021AddressCity, State/Province Zip/Postal Jonesborgh, ARCountry United StatesPhonePosition Held ELECTRCIANReason for leaving? RETIREDWere you terminated/discharged/laid off? NoIs this your current employer? NoMay we contact this employer at this time? YesDid you operate a commercial motorvehicle?NoWere you subject to the Federal MotorCarrier or Transport Canada SafetyRegulations while employed/contracted bythis employer/contractor?NoDid you perform any safety sensitivefunctions in this job, regulated by DOT,and subject to drug and alcohol testing?NoAreas DrivenMiles driven weeklyMost common truck drivenMost common trailerTrailer length10U.S. MilitaryBranch of Service NavyStart Date 10-1975End Date 10-1978Can you obtain your DD214? YesRank at discharge E 4Vehicle Accident RecordList ALL accidents and incidents for the past five (5) years. Be sure to list everything regardless of fault, severity, or motor vehicle type, be it personal or commercial vehicle. Were you involved in any accidents/incidents with any vehicle in the last 5 years (even if not at fault)?No AccidentsTraffic Convictions \ ViolationsList ALL tickets for the past five (5) years.Have you had any moving violations or traffic convictions in the past 5 years? Violation Date 06-2023Charge / Description Inattentive DrivingViolation City JONESBOROViolation State/Province ARIn Commercial Vehicle NoFined? YesLicense Suspended?License Revoked?Perform Community Service?Other Penalty?Fine Amount (if any): 100 - $199Please provide additional details includingcity or county location; if speeding, speedand zone. For any item answered "Other"provide additional informationOTHER11Traffic Convictions \ ViolationsList ALL tickets for the past five (5) years.Have you had any moving violations or traffic convictions in the past 5 years? Violation Date 03-2023Charge / Description Careless/Reckless DrivingViolation City POCAHONTASViolation State/Province ARIn Commercial Vehicle YesFined? YesLicense Suspended?License Revoked?Perform Community Service?Other Penalty?Fine Amount (if any): 100 - $199Please provide additional details includingcity or county location; if speeding, speedand zone. For any item answered "Other"provide additional informationOTHERSignatureFull Name Vance Columbus FitzgeraldIP Address 2600:100b:b136:fSignature Date/Time 10-23-2023 7:33 PMBy 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. APPLICANT'S STATEMENTI understand that any false or misleading statements in this application will be sufficient cause for rejection of my application if Candidate's Name and its division of Shaffer Trucking, hereinafter "the Company" has not already qualified me as a driver and for immediate disqualification if it has qualified me as a driver.If this application is for qualification as a Company Driver, I agree that the Company is not obligated to employ me. I acknowledge and agree that if I am offered employment, such offer is conditional upon my satisfactory completion of orientation and any other qualification standards or testing utilized by the Company. I further agree that, if I am employed as a Company Driver, I have the right to terminate my employment at anytime for any reason and that the Company has the same right. Any false, misleading or incomplete statement of the information requested in this application will be sufficient grounds for discharge from employment as a Company Driver.I agree that any claim or lawsuit relating to my service with the Company or any of its divisions must be filed no more than six (6) months after the date of the employment action that is the subject of the claim or 12lawsuit. I waive any statute of limitations to the contrary. I understand this driver qualification application, if complete, will be processed within ten (10) days after it's received by the "Company". To be qualified as a driver beyond this time period I should inquire as to whether or not applications are being accepted at that time. I agree to furnish such additional information and complete such examinations as may be required to complete my driver qualification file.I understand that the information I provide in this application, including but not limited to the information required by 49 CFR 391.21(b)(10)(11) may be used, and my previous employer(s) will be contacted, for the purpose of investigating my safety performance history as required by 49 CFR 391.23(d)(e) and 49 CFR 40.25.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. I HEREBY ACKNOWLEDGE THAT I HAVE READ, UNDERSTAND AND AGREE TO THE PRECEDING APPLICANT'S STATEMENT.THIS IS THE END OF THE APPLICATIONSigned Date: 10-23-2023 7:33 PMSigned:Federal FCRA Summary of Rights AcknowledgmentBy checking this box, I (a) acknowledgethat I have read and understand thefederal FCRA Summary of Rights andhave been given the opportunity tocopy/print the Summary of Rights and (b)agree to use an electronic signature todemonstrate my consent. An electronicsignature is as legally binding as an inksignature.YesPSP Disclosure and AuthorizationBy my check of this box, I represent that Iunderstand and agree to the aboveImportant Disclosure RegardingBackground Reports from the PSP OnlineService and Authorization, and, bychecking this box, I intend to execute thisdocument by electronic signature andconsent to the use of my electronicsignature to give effect to this document.Yes13Additional Consent or CertificationBy my check of this box, I represent that Iunderstand and agree to all of the abovedisclosures, notices, authorizations,releases, and certifications contained inthe above Disclosure and Authorization,and, by checking this box, I intend toexecute this document by electronicsignature and consent to the use of myelectronic signature to give effect to thisdocument.YesFCRA DisclosureBy checking the box, I (a) acknowledgethat I have read and understand the aboveand also have been given the opportunityto copy/print it, and (b) agree to use anelectronic signature to demonstrate myconsent. An electronic signature is aslegally binding as an ink signature.YesFCRA AuthorizationBy checking the box, I (a) acknowledgethat I have read and understand the aboveand also have been given the opportunityto copy/print it, and (b) agree to use anelectronic signature to demonstrate myconsent. An electronic signature is aslegally binding as an ink signature.YesEmployment Verification Acknowledgment and Release (DOT Drug and Alcohol) By my check of this box, I represent that Iunderstand and agree to the aboveDisclosure and Authorization for Releaseof Information for Employment Purposes49 CFR Part 391.23, DOT Drug andAlcohol Testing, and, by checking this box,I intend to execute this document byelectronic signature and consent to the useof my electronic signature to give effect tothis document.YesClearinghouse ReleaseBy checking the box, I (a) acknowledgethat I have read and understand the aboveYes14and also have been given the opportunityto copy/print it, and (b) agree to use anelectronic signature to demonstrate myconsent. An electronic signature is aslegally binding as an ink signature.Summary of Rights Under 15 U.S.C. Section 1681m(a) By checking the box, I (a) acknowledgethat I have read and understand theSummary of Rights Under 15 U.S.C.Section 1681m(a) and have been giventhe opportunity to copy/print the 1681mSummary of Rights and (b) agree to usean electronic signature to demonstrate myconsent. An electronic signature is aslegally binding as an ink signature.YesINVESTIGATIVE CONSUMER REPORT DISCLOSUREBy checking this box, I represent that Iunderstand and agree to the aboveInvestigative Consumer ReportDisclosure.YesUser Requested CopyUser requested a copy to be sent to thisemail addressvfitzgerald1957@gmail.com.Yes15DISCLOSURE FOR CONSUMER REPORTSIn connection with your employment or owner-operator (independent contractor) application, Candidate's Name 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:VANCE Columbus FITZGERALDSocial Security #:1944Signed Date: 10-23-2023VANCE Columbus FITZGERALD1714 Pace Road Ext Lot 10Pocahontas, AR 72455PHONE NUMBER AVAILABLEGender:16AUTHORIZATION FOR CONSUMER REPORTSI authorize Candidate's Name 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:VANCE ColumbusFITZGERALDSocial Security #:1944Signed Date: 10-23-2023VANCE Columbus FITZGERALD1714 Pace Road Ext Lot 10Pocahontas, AR 72455PHONE NUMBER AVAILABLEGender:17IMPORTANT DISCLOSUREREGARDING BACKGROUND REPORTS FROM THE PSP Online Service In connection with your application for employment with Candidate's Name 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. AUTHORIZATIONIf you agree that the Prospective Employer may obtain such background reports, please read the following and sign below: I authorize Candidate's Name 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:VANCE Columbus FITZGERALDSigned Date: 10-23-202318Consent for Limited Queries of the Federal Motor Carrier Safety Administration (FMCSA) Drug and Alcohol ClearinghouseI hereby provide consent to Candidate's Name 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 Candidate's Name 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 Candidate's Name 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. 10-23-2023VANCE Columbus FITZGERALD Date19DISCLOSURE AND AUTHORIZATIONDisclosure and Authorization for Procurement/Release of Information for Employment Purposes - Background Information: Disclosure is hereby made that Candidate's Name and its employees and agents: law enforcement and all other |
