FROM PREVIOUS EMPLOYER

REQUEST FOR INFORMATION FROM PREVIOUS EMPLOYER

Name of Driver Applicant

Social Security No

Data of Birth

CDL#

State

I authorize release of the information contained on this form as required under 49CFR 40.331, 382.413, 391.23 and other applicable requirements. I acknowledge that I have the right to due process as identiﬁed in 49CFR 391.23 to correct information submitted under this authorization.

DRIVERS: DO NOT WRITE BELOW THIS LINE. TO BE FILLED OUT BY PREVIOUS EMPLOYER ONLY!

The information being requested from the following company is done because it has been identiﬁed by the above driver applicant as a previous employer.

Previous Employer

Date Contacted

Address

Person Providing Information

SAFETY PERFORMANCE HISTORY - Please provide the following information on the above driver applicant:

Employed from

Straigth Truck

Tractor-Semi Trailer

Trailer Type

Bus

Reason Driver left?

Dischanrger

Resignation

Lay off

Military Duty

Other (Explain)

Date

City,Town,State

Of Injuries

#Of Fatalities

Vehicles Towed

Hazmat Spilled

Date

City,Town,State

Of Injuries

#Of Fatalities

Vehicles Towed

Hazmat Spilled

Date

City,Town,State

Of Injuries

#Of Fatalities

Vehicles Towed

Hazmat Spilled

Was driver involved in any DOT Accidents per 49CFR 390.5 during the previous three (3) years?

Yes

If YES, provide the following data elements for each as required by 49CFR 390.15(b)(1).

Does your company track accidents other than DOT Recordable (390.15)?

Yes

If yes , provide information on each such incident involving the driver applicant identiﬁed herein as appropriate.

DRUG & ALCOHOL INFORMATION

If driver applicant performed Safety-Sensitive Functions, provide answers to each of the following:

1. Did the driver take part in a DOT random drug & alcohol-testing program while under your control?

Yes

2. Did the driver test positive for a controlled substance in the last three (3) years ?

Yes

3. Did the driver have an alcohol test with a conﬁrmed BAC of 0.04% or greater in the last three (3) years ?

Yes

4. Did the driver refuse a required drug or alcohol test in the past three (3) years ?

Yes

5. Did the driver ever violate any other DOT agency drug or alcohol regulations?

Yes