Previous Employer Inquiry For Driving History & Safety Performance


Previous Employer: Name: _____________
Address: _____________
Phone: _____________
Email: _____________
Fax: _____________
Applicant
Applicant Name: _____________   Social Security:_____________   Date of Birth: _____________

Date of Employment: From: _____________ To _____________.
Prospective Employer/Contractor: BXB Express Freight Inc
6854 Lorel Ave Skokie Illinois 60077
Haris Begicevic
773-732-3204
Confidential Email: haris@bxbexpress.com
Confidential Fax: 7737548335
Prospective Employer's/Contractor's Agent _____________
_____________
_____________
_____________
Confidential Email: _____________
Confidential Fax: _____________

Section 1 (Applicant)
Applicant Authorization

I, _____________ hereby authorize _____________ to release and forward the information requested in sections2 and 3 of this document concerning my Accident History within the previous 3 years to _____________ (Prospective Employer/Contractor), and/or _____________ (third-party investigation firm).

Applicant's Signature: _____________ Date: _____________

This information is being requested in compliance with 49 CFR $$ 40.25 and 391.23.

In compliance with 49 CFR $$40.25(g) and 391.23(h), release of this information must be made in a form that ensures confidentiality, such as fax, email, or letter.

Section 2 (Previous Employer)
ACCIDENT HISTORY


The applicant named above was employed by you. _______ Yes _______ No

Employed as (Job Title) _________

From Date (mm/yyyy) _________

To Date (mm/yyyy) _________

Did he/she drive motor vehicle for you? _________ Yes _________ No

ACCIDENTS: Complete the following for any accidents included on your accident registrar ($390.15(b)) that involved the applicant in the 3 years prior to the application date shown above or check here if there is no accident register data for this driver.

Date Location Number of Injuries Number of Fatalities Hazmat Spill Preventable Description
             
             
             


Please provide information concerning any other accidents involving the applicant that were reported to government agencies or insurers or retained under internal company policies:

Signature _________

Title _________

Date _________

Completed By


Name: _________

Company: _________

Street: _________

City, State, Zip: _________

Phone: _________

Date: _________