REQUEST FOR INFORMATION
Previous Employer
NAME AND ADDRESS OF THIS FORM WAS (check appropriate box)
PREVIOUS EMPLOYER:
Mailed, Date
Faxed, Date
Emailed, Date
Received by Phone, Date
Name of Person Contacted
Name of Applicant:
Social Security No.: Date of Birth:
Dear Sir/Madam:
The above named individual has made application to this company for a position as
and states that he/she was employed by you as
from (m/y) to (m/y) .
In accordance with Section 391.23, we are obligated to request the information below from all previous employers of the
applicant that employed him/her to operate a commercial motor vehicle within the 3 years preceding
(date of application) .
Please complete the information below and return to us within 30 days, as required by Section 391.23(g). You may return the
information by telephone, fax, mail, or email.
Prospective Employer Attention:
Street: City, State, Zip:
Telephone: Fax: Email:
TO BE COMPLETED BY PREVIOUS EMPLOYER
SECTION 1: DRIVER IDENTIFICATION
The applicant named above was employed by us as. from (m/y) to (m/y)
Was driver involved in a safety-sensitive position subject to drug and alcohol testing under Part 40, check one . Yes No
SECTION 2: SAFETY PERFORMANCE HISTORY
1. Did he/she drive motor vehicles for you? Yes No If yes, what type? (circle) Straight Truck Tractor-Semitrailer Bus
Cargo Tank Doubles/Triples Other (Specify)
I hereby authorize you to release the following
information to :
(Prospective Employer)
for the purposes of investigation as
required by Section 391.23 of the Federal Motor
Carrier Safety Regulations
Applicant’s Signature Date
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signature
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2. Reason for leaving your employ: Discharged Resignation Lay Off Military Duty
If there is no safety performance history to report, check here , sign below and return.
ACCIDENTS:
Complete the following for any accidents included on your accident register (§390.15(b)) that involved the applicant in the 3
years prior to the application date shown above, or check here if there is no accident register data for this driver
Date | Location | No. of Injuries | No. of Fatalities | Hazmat Spill
1.
2.
3.
Please provide information concerning any other accidents involving the applicant that were reported to government agencies or
insurers or retained under internal company policies:
Any other remarks:
Signature:
Title: Date:
PREVIOUS EMPLOYER: KEEP A RECORD OF THIS REQUEST AND THE RESPONSE FOR ONE YEAR,
INCLUDING THE DATE, THE PARTY TO WHOM IT WAS RELEASED, AND A SUMMARY IDENTIFYING WHAT WAS PROVIDED.
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signature
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