.,
SIDE 1
~
I, (Print Name)
SAFETY PERFORMANCE HISTORY RECORDS REQUEST TO BE COMPLETED BY PROSPECTIVE EMPLOYEE
First, M.I., Last
Social Security Number Date of Birth
hereby authorize:
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
(date of employment application)
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 confidential fax number:
Prospective employer's confidential email address:
Applicant's Signature
This information is being requested in compliance with §40.25 and §391.23.
Date
TO BE COMPLETED BY PREVIOUS EMPLOYER
ACCIDENT HISTORY
The applicant named above was employed by us. Yes D No D
Employed as	from (m/y)
1. Did he/she drive motor vehicle for you? Yes D No D If yes, what type?
Cargo Tank D DoublesfTriples D Other (Specify)
2. Reason for leaving your employ: Discharged D Resignation D Lay Off D Military Duty D If there is no safety performance history to report, check here D, 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 D if there is no accident register data for this driver.
to (m/y)
Straight Truck D Tractor-Semitrailer D Bus D
Date
Location
No. of Injuries No. of Fatalities Hazmat Spill
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:
Signature:
Title: Date:
PREVIOUS EMPLOYER REMOVE CARBON BEFORE COMPLETING SIDE 2
@ Copyright 2004 J. J. KELLER & ASSOCIATES, INC. Neenah, WI . USA. (800) 327-6868 www.likeller.com.Printed in the United States
850-FS-C3 9620
I

-
.,
SIDE 1
SAFETY PERFORMANCE HISTORY RECORDS REQUEST TO BE COMPLETED BY PROSPECTIVE EMPLOYEE
I, (Print Name)
First, M.I., Last
hereby authorize:
Social Security Number 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
(date of employment application)
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 confidential fax number:
Prospective employer's confidential email address:
Applicant's Signature
This information is being requested in compliance with §40.25 and §391.23.
Date
TO BE COMPLETED BY PREVIOUS EMPLOYER
ACCIDENT HISTORY
The applicant named above was employed by us. Yes D No D
Employed as	from (m/y)
1. Did he/she drive motor vehicle for you? Yes D No D If yes, what type?
Cargo Tank D DoublesfTriples D Other (Specify)
2. Reason for leaving your employ: Discharged D Resignation D Lay Off D Military Duty D If there is no safety performance history to report, check here D, 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 D if there is no accident register data for this driver.
to (m/y)
Straight Truck D Tractor-Semitrailer D Bus D
Date
Location
No. of Injuries No. of Fatalities Hazmat Spill
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:
Signature:
Title: Date:
PREVIOUS EMPLOYER REMOVE CARBON BEFORE COMPLETING SIDE 2
@ Copyright 2004 J. J. KELLER & ASSOCIATES, INC. Neenah, WI . USA. (800) 327-6868 www.llkeller.com.Printed in the United States
850-FS-C3 9620
I