SAFETY PERFORMANCE PART 1: TO BE COMPLETED BY PROSPECTIVE EMPLOYEE I, (Print Name) First * M.I Last * Social Security Number Hereby authorize: Date of Birth Previous Employer Email Street Telephone City, State, Zip Fax No To release and forward the information requested by section 3 of this document concerning my Alcohol and Controlled Substances Testing records within the previous 3 years from (employment application date) To: Prospective Employer: Attention Telephone Street City, State, Zip 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. Prospective employer’s fax number Prospective employer’s email address Applicant's Signature * signature keyboard Clear Date * This information is being requested in compliance with §40.25(g) and 391.23. PART 2: TO BE COMPLETED BY PREVIOUS EMPLOYER ACCIDENT HISTORY The applicant named above was employed by us. Yes No Employed as from (m/y) to (m/y) 1. Did he/she drive motor vehicle for you? Yes No If yes, what type? Straight Truck Tractor-Semitrailer Bus Cargo Tank Doubles/Triples Other (Specify) 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 1 Location # Injuries # Fatalities Hazmat Spill Text 2 Text Text Text Text Text 3 Text Text Text Text Please provide information concerning any other accidents involving the applicant that were reported to government agencies or insurers or retained under internal company policies: Text Any other remarks: Text Signature signature keyboard Clear Name Name First First Last Last Title Date If you are human, leave this field blank. Submit Start Over
