Previous Employer Verification-Online Form PART 1: TO BE COMPLETED BY PROSPECTIVE EMPLOYEE PREVIOUS EMPLOYER INFORMATION COMPANY NAME TODAY'S DATE COMPANY ADDRESS COMPANY CITY COMPANY STATE COMPANY ZIP CODE COMPANY TEL OR FAX YOUR FIRST NAME YOUR MIDDLE NAME YOUR LAST NAME PLEASE USE YOUR MOUSE OR FINGER TO SIGN IN THE BOX BELOW: YOUR SOCIAL SECURITY NUMBER YOUR DATE OF BIRTH EMPLOYED FROM (MONTH/YEAR) EMPLOYED TO (MONTH/YEAR) CONTACT INFORMATION Your Full Name (*required) Your Email (*required) Subject Your Message PART 2: TO BE COMPLETED BY PREVIOUS EMPLOYER EMPLOYMENT VERIFICATION 1. THE APPLICANT NAMED ABOVE WAS EMPLOYED BY US: Yes No 2. THE APPLICANT NAMED ABOVE WAS EMPLOYED AS: FROM (MONTH/YEAR) TO (MONTH/YEAR) 3. DID HE/SHE DRIVE A MOTOR VEHICLE FOR YOU? Yes No 4. IF YES, WHAT TYPE? (check all that apply) STRAIGHT TRUCK TRACTOR SEMITRAILER CARGO TANK DOUBLES/TRIPLES OTHER: 5. REASON FOR LEAVING YOUR EMPLOYMENT DISCHARGED LAY OFF RESIGNATION MILITARY DUTY OTHER: 6. IS APPLICANT ELIGIBLE FOR RE-HIRE? Yes No IF DRIVER WAS NOT EMPLOYED BY YOU, DID NOT DRIVE A MOTOR VEHICLE FOR YOU OR WAS NOT SUBJECT TO DEPARTMENT OF TRANSPORTATION TESTING AND SAFETY PERFORMANCE REQUIREMENTS WHILE EMPLOYED BY YOU, CHECK BELOW AND COMPLETE BOTTOM SECTION OF PART 2, SIGN AND RETURN. No ACCIDENT HISTORY (Last 3 Years) Complete the following for any accidents including on your accident register (ยง390.15(b)) that involved applicant in the 3 years prior to the application date shown above, or check below if there is no accident register data for this driver. No ACCIDENT DATE NATURE OF ACCIDENT LOCATION NUMBER OF INJURIES NUMBER OF FATALITIES HAZMAT SPILL? Yes No ACCIDENT DATE NATURE OF ACCIDENT LOCATION NUMBER OF INJURIES NUMBER OF FATALITIES HAZMAT SPILL? Yes No Other accidents involving the applicant that were reported to government agencies or insurers or retained under internal company policies: DRUG AND ALCOHOL HISTORY (Last 3 Years) 1. WAS DRIVER SUBJECT TO DEPARTMENT OF TRANSPORTATION TESTING REQUIREMENTS? Yes No 2. HAS THIS PERSON HAD AN ALCOHOL TEST WITH THE RESULT OF 0.04 OR HIGHER ALCOHOL CONCENTRATION? Yes No 3. HAS THIS PERSON TESTED POSITIVE, ADULTERATED OR SUBSTITUTED TEST SPECIMEN FOR CONTROLLED SUBSTANCES? Yes No 4. HAS THIS PERSON REFUSED TO SUBMIT TO A POST-ACCIDENT, RANDOM, REASONABLE SUSPICION, OR FOLLOW-UP ALCOHOL OR CONTROLLED SUBSTANCE TEST? Yes No 5. HAS THIS PERSON COMMITTED OTHER VIOLATIONS OF SUBPART B OF PART 382, OR PART 40? Yes No 6. IF THIS PERSON HAS VIOLATED A DOT DRUG AND ALCOHOL REGULATION, DID THIS PERSON COMPLETE A SAP-PRESCRIBED REHABILITATION PROGRAM IN YOUR EMPLOYMENT, INCLUDING RETURN-TO-DUTY AND FOLLOW-UP TESTS? N/A Yes No COMPLETED BY COMPANY NAME DATE STREET ADDRESS CITY STATE ZIP CODE TEL OR FAX COMPLETED BY (Type Name) TITLE PLEASE USE YOUR MOUSE OR FINGER TO SIGN IN THE BOX BELOW: CONTACT INFORMATION Your Full Name (*required) Your Email (*required) Subject Your Message
