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SAFETY PERFORMANCE HISTORY RECORDS REQUEST

SAFETY PERFORMANCE

PART 1: TO BE COMPLETED BY PROSPECTIVE EMPLOYEE

I, (Print Name)

Hereby authorize:

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

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

The applicant named above was employed by us.
1. Did he/she drive motor vehicle for you?
If yes, what type?
2. Reason for leaving your employ:
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.
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:
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