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Part lA: To Be Completed bv Prospective Emplover <br />Prospective Employer: Visu-Sewer. Inc. <br />Attention: Lindsay Golner <br />Address:W230 N4855 Betker Drive <br />City, State, Zip: Pewaukee. WI 53072 <br />Phone: 262-695-2340 Fax: 262-695-2359 <br />Email: visu-info@visu-sewer.com <br />In compliance with 49 CFR $40.25(9) and $391.23(h), release of this information is required and must be in a written form <br />that ensures confidentiality such as fax, email, or post mail. <br />Send or forward information fax or email within <br />Part 2: To Be Completed By Previous Emplover <br />General Previous Employment Information: <br />The named applicant was employed by us as a DOT-regulated driver (as defined by 49 CFRg390.5) from <br />(mrr/yyyy) to (rur/yyyy)_ <br />l. During this time, the applicant operated (please check all applicable vehicle types): <br />Straight Truck E Semi Tractor-Trailer ! Bus/Motor Coach I Cargo Tank-Trailer I Double/Triple Trailers I <br />Other (Specify) <br />2. Reason for leaving your employ: lVoluntary Resignation E Involuntary Discharge tr Lay Off <br />! Military or Other Leave of Absence ! Other (Specify) <br />3. Is the above named applicant eligible for rehire? Yes E No E <br />Part 3: To Be Completed Bv Previous Emplover <br />Accident History: <br />Ifthe above named applicant was not involved in any accidents as defined by 49 CFR $390.5*, while employed by your <br />organization check here n and go to Part 4 below: <br />For any accidents as defined by 49 CFR$390.5*, and as listed on your required accident register (49 CFR$390. l5(b)), <br />involving the above name applicant in the 3 years prior to the application date stated above, complete the following: <br />Date Iocation No. of Injuries No. of Fatalities Hazmat Spill <br />YeslNo E <br />YesnNo ! <br />YesnNo E <br />l. <br />2.