Request for Driver’s Safety Performance History Request for Driver's Safety Performance History Step 1 of 2 50% Previous Employer Name: Phone:Fax: Employed From Date: MM slash DD slash YYYY Employed To Date: MM slash DD slash YYYY Past Employer to complete Drug & Alcohol Information(As required by FMCSR Part 391.23 & 40.25)If no Drug & Alcohol information is available on the above named applicant, check here No information available Any alcohol test with a result of 0.04 or higher alcohol concentration? Yes No Any verified positive drug test? Yes No Any refusals to be tested (including verified adulterated or substituted drug test results?) Yes No Any other violations of DOT agency drug & alcohol testing regulations? (Part 382 or Part 40) Yes No If yes to any of the above questions, please provide date test was failed or refused. Please provide documentation of successful completion of a SAP's evaluation, prescribed treatment and return-to-duty requirements (including follow-up tests) if they remained in your employ. If this information is not available from the previous employer, you as a prospective employer must get this Information from the driver/applicant. Date test was failed or refused: MM slash DD slash YYYY Accident Information (As required by 391.23(d)(1)(2))Please provide the following information on any accidents (per 390.5 and/or from your Accident Register FMCSR 391.15) which the above named driver/applicant was involved within the past three years while under your employment. Additional detailed information on minor Date: MM slash DD slash YYYY Location (nearest city/town & state): Vehicles towed? Hazmat spill? # of Fatalities: # of injuries: Date: MM slash DD slash YYYY Location (nearest city/town & state): Vehicles towed? Hazmat spill? # of Fatalities: # of injuries: If there is no accident information for this driver, please check here: No accident information available Work History Information: Please provide the following information on driver/applicant:He/she was employed for you as a: From Date: MM slash DD slash YYYY To Date: MM slash DD slash YYYY Check all equipment used: Straight Trucks Tractor/Trailer Bus Dry Van Flatbed Reefer Hopper Dump Lowboy Tanker Container Doubles Triples Other Other: Was he/she a: Company Driver Contractor Contractor's Driver Other Other: Bonded: Yes No General Area Traveled: OTR Local Regional Commodities transported: Convicted of any traffic violations? Yes No If yes, please list all including date and type:License(s) suspended. revoked or denied? Yes No If yes, please explain:Reason for Leaving?Eligible for Rehire? Yes No Upon Review Please explain:Additional Comments:Name: First Last Title: Signature:Today's Date: MM slash DD slash YYYY
