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Click here or scroll down to respond to this candidateTransForce, Inc.Street Address Walker LaneSuite Street Address
Alexandria, VA Street Address
PHONE NUMBER AVAILABLEStreet Address -12-2021 9:32:25AM CDTIntelliAppJoin more than 10,000 satisfied drivers across the US and Canada, and an employer invested in your success."TransForce is great about setting you up to succeed. They match your skill level with customer needs and never put you in a situation you can't handle." -Aaron, Alexandria, VAStart your application today!Personal InformationReferral Code: indeedName Samuel Lee JacksonResidence 3 years or longer (If No,previous addresses shown below)YesCurrent Address 11040 Fall DriverCity, State/Province Zip/Postal Indianapolis, IN 46229 Country United StatesResidence 3 years or longer (If No,previous addresses shown below)YesSSN/SIN 4847Date of BirthPrimary Phone PHONE NUMBER AVAILABLECell Phone PHONE NUMBER AVAILABLEPreferred method of contact Primary PhoneBest time to contact you AnyEmail EMAIL AVAILABLEYes, I agree to receive informationconcerning future opportunities orpromotions from TransForce, Inc. by emailor other commercial electroniccommunications.YesWould you like to receive communicationfrom TransForce, Inc. via text message?By participating, you consent to receivetext messages sent by an automaticYes1telephone 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 thatTransForce, Inc.'s service providerreceives in real time and logs your textmessages with TransForce, Inc..Company QuestionsGENERAL INFORMATIONWhich Commercial Class License do youhave?AHow much CDL driving experience do youhave?3 years +How many violations have you been citedfor in the last 12 months?How many accidents have you beeninvolved in during the last 12 months?Job ID passed on the url 5180What location are you applying to? IN, Indianapolis Where did you see our job advertised? IndeedIf you selected "Other" above, pleasespecify the source:Type of Route you want: Local DeliveryHave you have ever served in any branchof the United States military?YesIf you are applying as an Owner Operatorin California, who are you contracted with?Your experience: 5+ yearsPreferred Job Shift: AnyTypes of Job: Full TimeDo you have experience driving a vehicleequipped with a Manual Transmission?YesDo you have experience using anElectronic Logging Device for Hours ofService Compliance?NoPlease list the devices you are familiarwith:Do you have a "Fast" pass? No2Do you have a TWIC card? NoDo you currently have a valid passport? NoAre you registered for the FMCSAClearinghouse?NoWhere do you want to work? MidwestHave you tested positive, or refused totest, on any pre-employment drug screenwithin the previous 2 years?NoIn case of Emergency, notify (list name,address, phone and relationship):Daisy Jackson 11040 Fall DriveIndianapolis Indiana 46229LicensesLicense Number 625State/Province INCountry United StatesLicense Class Class AOriginal Issue Date 10-26-2019License Expiration Date 10-26-2021Physical Expiration Date 10-26-2019Current License YesCommercial Driver License YesEndorsementsTanker Endorsement YesHAZMAT Endorsement NoX Endorsement NoDoubles Triples Endorsement NoOther Endorsement YesEmployment / UnemploymentUnemploymentStart Date 05-2021End Date 06-2021CommentSecurAmerica LLCCompany SecurAmerica LLC3Start Date 03-2019End Date 04-2021Address 3399 Peachtree Road Ne suite 1City, State/Province Zip/Postal Atlanta, GA 30326Country United StatesPhone PHONE NUMBER AVAILABLEPosition Held Security guardReason for leaving? Company was brought outWere 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?Did you perform any safety sensitivefunctions in this job subject to drug andalcohol testing?Areas DrivenMiles driven weeklyPay Range (cents/mile)Most common truck drivenMost common trailerTrailer lengthXexpress Truck driver trainingCompany Xexpress Truck driver trainingStart Date 09-2019End Date 04-2020Address 2330 Enterprise Park PlCity, State/Province Zip/Postal Indianapolis, IN 46218 Country United StatesPhone PHONE NUMBER AVAILABLEPosition Held Professional truck driver trainedReason for leaving? Covid194Were you terminated/discharged/laid off? NoIs 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 Across the city of IndianapolisMiles driven weekly 500-1000Pay Range (cents/mile) $20.00 an hourMost common truck driven Tractor-TrailerMost common trailer ContainerTrailer length 53 feet or moreUnemploymentStart Date 10-2011End Date 02-2018Comment I am a retired veteran and I retired frominterstates brandsInterstate Brands Corp.Company Interstate Brands Corp.Start Date 06-1991End Date 10-2011Address 12 East Armour BoulevardCity, State/Province Zip/Postal Kansas City, MO 64111 Country United StatesPhone PHONE NUMBER AVAILABLEFax PHONE NUMBER AVAILABLEPosition Held Professional truck driverReason for leaving? RetiredWere you terminated/discharged/laid off? NoIs this your current employer? No5May 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 Across the MidwestMiles driven weekly 1000-1500Pay Range (cents/mile) $15.00 an hourMost common truck driven Tractor-TrailerMost common trailer VanTrailer length 45 to 52 feetU.S. MilitaryBranch of Service ArmyStart Date 06-1974End Date 06-2006Can you obtain your DD214? YesRank at discharge E7Trucking SchoolStart Date 06-1990End Date 10-1990School Ctt truck driving schoolCity, State/Province Indianapolis, INCountry USPhoneDid you graduate? YesWere you subject to the Federal MotorCarrier or Transport Canada SafetyRegulations while attending this truckschool?Yes6Did you perform any safety sensitivefunctions at this truck school, regulated byDOT, and subject to drug and alcoholtesting?YesGPA 3Hours of Instruction 40Border Crossing NoLog Books YesFederal Motor Carrier Regulations YesHazardous Materials YesMotor Vehicle Record1. Has any license, permit or privilege everbeen denied, suspended or revoked forany reason?YesDate 02-1992Comment Miss the date paying my ticket2. Have you ever been convicted of drivingduring license suspension or revocation, ordriving without a valid license or an expiredlicense, or are any charges pending?No3. Have you ever been convicted for anyalcohol or controlled substance relatedoffense while operating a motor vehicle, orare any charges pending?No4. Have you ever been convicted forpossession, sale or transfer of an illegalsubstance (including but not limited to,marijuana, amphetamines, or derivativesthereof) while on duty, or are any chargespending?No5. Have you ever been convicted ofreckless driving, careless driving orcareless operation of a motor vehicle, orare any charges pending?No6. Have you ever tested positive, orrefused to test on a pre-employment drugor alcohol test by an employer to whomyou applied, but did not obtainsafety-sensitive transportation workcovered by DOT agency drug and alcoholtesting rules in past three years, or haveyou ever tested positive or refused to teston any DOT-mandated drug or alcoholNo7test?7. Have you ever been convicted ofexcessive speeding (15 mph or greater) ina motor vehicle or are any chargespending?NoPlease explain and include the date ofconviction:Vehicle Accident RecordPlease list ALL accidents and incidents regardless of severity or type of vehicle operated at the time of the crash.Were you involved in any accidents/incidents with any vehicle in the last 3 years (even if not at fault)?Type of Accident / Incident Non-InjuryDate of Accident / Incident 03-2019Hazmat Accident / Incident NoWas the vehicle towed away? YesCity IndianapolisState/Province INWere you in a commercial vehicle? NoIf yes, was this a Department ofTransportation recordable accident?Were you at fault? YesWere you ticketed? NoDescription It was raining hard and I ran the red light on my carTraffic Convictions \ ViolationsHave you had any moving violations or traffic convictions in the past 3 years? No ViolationsCriminal RecordHave you ever been convicted of a crime? NoDo you have any deferred prosecutions? NoDo you have criminal charges pending? NoNo8Have you ever pled "guilty" to, beenconvicted of, or pled "no contest" to afelony?If you have any felony convictions, do youcurrently hold a minister's permit to enteror exit Canada?NoHave you, within the last five years, pled"guilty" to, been convicted of, hadprosecution deferred in connection with, orpled "no contest" to a misdemeanor?NoSignatureFull Name Samuel Lee JacksonIP Address 2607:fb90:f0e8:4Signature Date/Time 06-12-2021 9:32 AMBy 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: 06-12-2021 9:32 AMSigned: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 checking the box, I (a) acknowledgethat I have read and understand the PSPYes9Disclosure and Authorization and alsohave been given the opportunity tocopy/print it, and (b) agree to use anelectronic signature to demonstrate myconsent. An electronic signature is aslegally binding as an ink signature.Additional Consent or CertificationBy 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 Disclosure and 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 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.YesClearinghouse ReleaseBy 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.Yes10Conditional Offer LetterBy checking the box, you attest that youhave read and understand the conditionsof employment set forth in this document.YesUser Requested CopyUser requested a copy to be sent to thisemail address sam678760@gmail.com.Yes11NOTIFICATION AND RELEASE TO CONDUCT BACKGROUND CHECKS In connection with your employment or application for employment and in accordance with pertinent laws, TransForce, Inc. may obtain or assemble consumer reports and/or investigative consumer reports (collectively, "Reports" related to information concerning your: previous employment (including employers, dates of employment, reasons for termination, etc.), academic history, verification of references and verification of other information supplied by you, professional credentials, drug/alcohol use in violation of law and/or company policy, driving record, accident history, workers compensation claims, criminal history records and information about your character, general reputation, and personal characteristics (collectively, "Information"). Information may be obtained from government agencies, educational institutions, TransForce clients, personal references, personal interviews and other Information sources(collectively, "Suppliers"). These reports will be obtained from HireRight, Asurint and other credit/consumer reporting agencies. Upon providing proper identification and subject to applicable legal requirements and restrictions, you have the right to request the nature and substance of all Information in TransForce, HireRight and Asurint files pertaining to you, as well as information including, but not limited to: (i) whether any Reports have been provided by TransForce, HireRight or Asurint to other parties; (ii)identification of any Suppliers utilized by TransForce, HireRight or Asurint in compiling such Reports; and (iii) identification of any recipients of Reports furnished by TransForce, HireRight or Asurint within certain statutorily-prescribed time periods preceding your request. TransForce may be contacted by mail at 5520 Cherokee Ave Ste. 200, Alexandria, VA 22312, or by phone at PHONE NUMBER AVAILABLE AUTHORIZATION FOR RELEASE OF INFORMATIONI hereby authorize TransForce to obtain information and disclose Information to its customers ("Customers"), if applicable, for the purpose of making a determination as to my eligibility for employment, promotion, retention or other lawful purpose. If hired, I authorize TransForce and TransForce Customers, if applicable, to retain this document on file to act as ongoing authorization for the procurement and assembly of Reports at any time during my employment or contract period. As permitted by law, I fully release TransForce, TransForce Customers and Suppliers from all claims of damages related to the investigation of my background and provision of Information as set forth in this document. I agree that if hired by TransForce, information in TransForce's possession may be supplied by TransForce to TransForce Customers for legally permissible purposes which maybe required by the Federal Motor Carrier Safety Regulations.By signing below, I certify that: (i) all information provided herein is complete and accurate; (ii) I have read and fully understand this disclosure and authorization for release; (iii) prior to signing I was given an opportunity to ask questions and to have those questions answered to my satisfaction; (iv) I execute this authorization voluntarily and with the knowledge that the Information obtained pursuant to this authorization could affect my eligibility for employment, independent contractor status, promotion, retention or other lawful purpose: (v) I understand I may review this document with legal counsel prior to signing; (vi) I authorize TransForce and any person or entity contracted by TransForce to furnish the above-mentioned Information; and(vii ) facsimile or e-mail copies of this authorization are as valid as an original. AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATIONI hereby authorize Concentra Medical Networks, Clinical Reference Laboratory and any other laboratory or medical facilities used by TransForce to release to TransForce, Inc. ("the Company" and its designated agents, including Medical Review Officers, Substance Abuse Professionals, and rehabilitation personnel, the results of laboratory tests and the fitness determination findings from the medical examination report, to which I have consented for the purpose of determining the presence of drugs and/or alcohol in my body or my medical fitness to operate a commercial vehicle. I expressly understand and agree that the Company will review the results of these tests in connection with making a decision concerning my employment.I understand that consistent with guidance issued by the Federal Motor Carrier Safety Administration, TransForce shares ownership and responsibility for ensuring that the Part 382 & 391.41-53 testing regulations are followed with its clients and customers who perform regulated functions. Therefore, I hereby authorize TransForce to release the results of any of any drug, alcohol or medical test that I submit which are required by Part 382 & 391.41-53 of the Federal Motor Carrier Safety Regulations, to any of its motor carrier customers to whom I am assigned or for whom I may perform work, meet the for the purpose of permitting those customers to ensure that they can meet the obligations imposed upon them by Part 382 & 391.41-53. This authorization shall become effective immediately. I understand that I have the right to receive a copy of this authorization upon request. Printed Name:Samuel Lee JacksonSocial Security #:4847Signed Date: 06-12-2021Samuel Lee Jackson11040 Fall DriverIndianapolis, IN 46229PHONE NUMBER AVAILABLEGender:12IMPORTANT DISCLOSUREREGARDING BACKGROUND REPORTS FROM THE PSP Online Service In connection with your application for employment with TransForce, 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. AUTHORIZATIONIf you agree that the Prospective Employer may obtain such background reports, please read the following and sign below: I authorize TransForce, 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. Printed Name:Samuel Lee JacksonSigned Date: 06-12-202113Consent for Limited Queries of the Federal Motor Carrier Safety Administration (FMCSA) Drug and Alcohol ClearinghouseI hereby provide consent to TransForce, Inc. 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 TransForce, Inc. 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 TransForce, Inc. to conduct a limited query of the Clearinghouse, TransForce, Inc. 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 TransForce, Inc. indicates that drug or alcohol information exists about me in the Clearinghouse, the FMCSA will not disclose that information to TransForce, Inc. unless I give additional specific consent within the Clearinghouse. However, I understand that TransForce, Inc. 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. 06-12-2021Samuel Lee Jackson Date14ACKNOWLEDGEMENT OF COMPLIANCE RESPONSIBILITIESSection 1TransForce acts as the agent for its customers in helping them meet the Federal Motor Carrier Safety Regulations (FMCSRs) for each driver that they use. Hence, we may be required to share employment records with them. I hereby release and permit TransForce to provide copies of any records regarding my employment to the motor carriers to whom I am assigned or to any other client or party deemed relevant by TransForce.Section 2Section 383.21 of the FMCSRs states that no person who operates a commercial motor vehicle requiring a Commercial Driver's License(CDL) may have more than one license at any time. I certify that I have only one license. Section 3Section 383.31 of the FMCSRs requires that any time you are convicted of violating a state or local traffic law (other than parking) you must report the conviction to your employing motor carrier and the state that issued your license within 30 days. The report to the state need not be made if the violation occurred in your state of licensure. A form has been provided to you to facilitate your compliance with this requirement. Also, Sections 383.33 and 391.15 of the FMCSRs require that you notify your employer of any revocation or suspension of your driver's license by the end of the next business day. I promise to comply with these requirements. Section 4Section 395.8(j)(2) of the FMCSRs requires that each time you begin work for a new motor carrier, or resume work for a motor carrier for whom you drive intermittently, you must provide a signed statement giving your total time on-duty for the immediately preceding seven days. Alternatively, you may furnish a copy of your daily record of duty status (log) for each of the seven preceding days. Because any work done at the direction of a motor carrier or any compensated time for a non-motor carrier is considered on-duty time, we require that you notify us if you work for any other person or company while in the employment of TransForce. I promise to comply with these requirements.Section 5Section 395.3 of the FMCSRs prohibits you from driving more than 11 hours (following 10 consecutive hours off-duty), from driving for any period after having been on-duty following the 14th consecutive hour after first coming on duty (following 10 consecutive hours off-duty), from driving after having been on-duty for 60 hours in any 7 consecutive days (if the motor carrier does not operate every day of the week) or 70 hours in any period of 8 consecutive days (if the motor carrier operates every day of the week). You may not accept an assignment from TransForce or any of its customers without having the available hours to complete the assignment within the legal time limits. No motor carrier may require or permit you to violate these rules. I certify that I understand and will comply with these requirements. Section 6Section 390.3(e)(2) requires that every driver and employee be instructed in and shall comply with all applicable regulations. The driver orientation process discusses relevant rules and regulations applicable to you. Training and informational materials will be provided to you throughout your employment with TransForce. In addition, the Federal Motor Carrier Safety Regulations (FMCSRs) are available to you upon request. By initialing here, you are indicating that you will comply with all applicable Federal and State regulations, and will seek guidance from TransForce operations staff for any regulations you are unfamiliar with. Section 7TransForce provides each driver with a copy of our Work Rules that set forth our performance and attendance requirements. I acknowledge that I have received a copy of TransForce's Work Rules. Section 8Any applicant who does not have a current, valid medical examiners certificate, or who is required by TransForce to obtain a new medical examiners certificate because there is doubt as to his physical qualification, must successfully complete and pay for a physical exam before beginning work with TransForce and furnish a copy of such certificate accompanied with the medical examination report for filing under FMCSR 391.43(f), 391.45, 391.51 & 391.53. I will comply with this requirement if applicable. Section 9Section 382.601 of the Federal Motor Carrier Safety Regulations requires motor carriers to |
