Laserfiche WebLink
YSYiilu*s,jHHHf** <br />Safety Performance History Record <br />(DoT-Regulated Employees) <br />S:\Accountitrg\FoRMs\Appltcationslsafety Perlomance History Record (DOT Regulatcd Employees) docx <br />W230 N4855 Betker Drive, Pewaukee, WI 53072 <br />262-695-2340 1-800-876-8478 <br />FAX 262-695-2359 <br />Step 3: Previous Employer <br />} Complete the required information in Parts 2,3 and 4 <br />) Make a copy of the form for your records <br />) Forward the completed form back to the <br />prospective Employer (see Part 1A) <br />Step 4: Prospective Employer <br />) Complete the required information in Parts 44' and 48 <br />) Record receipt of form from previous employer <br />F Retain copy in the applicant's driver qualification <br />File ifhired, and discard temporary record retained <br />from Step 2. Ifnot hired, retain as dictated by company <br />policy <br />Instructions: <br />Step I Prospective Employee (Drive Applicant) <br />) Complete the required information in Part I <br />F Sign and date where indicated in Part 1 <br />) Copy form for your record <br />F Forward original to Prospective Employer <br />Step 2: Prospective Employer <br />! Complete the required information in Part 1A <br />) Have Prospective employee sign and date the form, <br />ifnot already done from Step I <br />) Make copy of the form to be set aside as a <br />temporary record <br />F Forward form to Previous Employer <br />PART l: To Be Completed Bv Prospective Emplovee (Driver Applicant) <br />I, (Printed Name) <br />regulated <br />hereby authorize the following previous DOT- <br />(First, Middle, Last) <br />Employer to release and forward all requested information contained herein concerning my safety performance history (as <br />required by <br />49CFR$40.25and$391.23fortheprevious3yearsfrominc1uding: <br />(date of application) <br />1. General employment information; <br />2. DOT-recordable accidents (as defined by 49 CFR $390.5) involving the above named driver; and <br />3. DOT-regulated Alcohol and Controlled Substance Testing results/information. <br />Previous Employer: <br />(Compmy Nm)(ComtNDy Rept5ehtative/Pteviot8 Superuisor) <br />Address:Phone No.:Fax No. <br />City, State, Zip Email. <br />Applicant's Signature Today's Date <br />Social Security Number Date of Birth