The Federal Motor Carrier Safety Regulations require all previous employers of this applicant to respond to this request for information within 30 days. Failure to comply with this request is in violation of 49CFR 391.23 and 40.25, for which you may be prosecuted. Questions concerning the requirements of this regulation should be directed to the Minnesota Division Office of the Federal Motor Carrier Safety Administration at 651-291-6150, during business hours.
TO: |
(enter former employer's name) |
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________________________________________________ DATE: _________________ |
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Former Employer’s Name |
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(enter mailing address) |
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Mailing Address |
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(enter city / state / zip) |
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City / State / Zip |
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_____________________ |
(enter fax number) |
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Telephone # |
Fax Number |
(enter name)
I, ______________________________, hereby authorize ___________________________ to release to all records of
employment, including assessments of my job performance, ability, and fitness, including the dates of any and all alcohol or drug tests, with confirmed results, and/or my refusal to submit to any alcohol and drug tests and any
rehabilitation completion under direction of Substance Abuse Professional (SAP) and/or Medical Review Officer (MRO) to each and every company (or their authorized agents) making such request in connection with my application for employment with said company. I, hereby, release the above named company, and its employees, officers, directors, and agents from any and all liability of any type as a result of providing the following information to the below mentioned person and/or company.
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Applicant’s Signature & Date |
_______________________________ |
___________________ |
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Witness’s Signature & Date |
_______________________________ |
___________________ |
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REQUEST FROM: |
(enter company name) |
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Company: |
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_______________________________________________________ |
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Address/City/State/Zip: |
_______________________________________________________ |
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Telephone Number: |
(enter phone number) Fax Number: (enter fax number) |
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Contact Person & Title |
_________________________________ |
_____________________ |
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NAME OF APPLICANT: |
_________________________________ SSN _________________ |
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JOB APPLYING FOR: |
_______________________________________________________ |
INQUIRY INTO EMPLOYMENT HISTORY, PRECEDING 3 YEARS
•Did applicant work for you as a ____________________________ from ____/____/____ to ____/____/____ YES or NO IF NO, please explain:
_______________________________________________________________________________
•If employed as driver, please answer the following: Company Driver? ______ Owner/Operator? ______ Other? ______
Type of truck(s) and/or truck/tractor(s) operated: ______________________________________________________
Commodities transported: ____________________________ Area of operations: ____________________________
• Accidents? YES or NO IF YES, please give date(s) and brief description of each accident:
__________________________________________________________________________________________
•Why did this employee leave your company?
__________________________________________________________________________________________
• Would you re-employ this person? YES or NO IF NO, please explain:
__________________________________________________________________________________________
•Additional comments:
__________________________________________________________________________________________
INQUIRY FOR ALCOHOL AND CONTROLLED SUBSTANCES INFORMATION, PRECEDING 2 YEARS
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Alcohol tests with a result of 0.04 or greater? ………. |
YES or NO |
If yes, please give date(s): ________________ |
• Verified positive controlled substances test results? … |
YES or NO |
If yes, please give date(s): ________________ |
• Refusals to be tested? ………………………………… |
YES or NO |
If yes, please give date(s): ________________ |
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Was rehabilitation completed as required? …………... |
YES or NO |
If yes, please give date(s): ________________ |
Person providing the above information:
Name: ________________________________________________ Title: ______________________________
Company: ________________________________________________ Date: ______________________________