PART 1: TO BE COMPLETED BY PROSPECTIVE EMPLOYEE
To:
In compliance with §40.25(g) and 391.23(h), release of this information must be made in a written form that ensures confidentiality, such as fax, email, or letter.
This information is being requested in compliance with §40.25(g) and 391.23.
PART 2: TO BE COMPLETED BY PREVIOUS EMPLOYER
ACCIDENT HISTORY
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.
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: