INQUIRY TO PAST EMPLOYER

From - Prospective Employer/Contractor	To - previous employer
Company : BXB Express Freight Inc Individual : Haris Begicevic Address : 6854 Lorel Ave City : Skokie State : Illinois Zip : 60077	Company : _____________ Individual : _____________ Address : _____________ City : _______ State : _______ Zip : _______

Dear Motor Carrier: The person listed below has made application to this company for employment or contracting as a Driver and states that he/she was employed by you as ______ from ______ to ______. If these dates are not correct please provide From ______ and To ______ The applicant has waived any claim of liability against you company for information submitted in response to the inquiry - See release form at bottom of this page

Name of Applicant: ____________

Social Security Number of Applicant: ____________. Date of Birth: ____________

1. Is the employment record with your company, including dates, correct as stated above? ____________

2. What kind of work did applicant do? ____________

3. If employed as a driver, Specify type of equipment ____________

4. If Tractor-Trailer please specify type: Dry Van Tanker Flatbad Reefer Dump Hopper

5. Total Miles Driven ____________

6. Number of accidents ____________. Number preventable ____________

7. Was applicant's drivers license ever suspended or revoked? ____________

8. Reason for leaving your employ : ____________ Discharged ____________ Laid off ____________ Resigned

9. Was applicant's general conduct satisfactory? _______ Yes _______ No

10. Is applicant competent for the position applicant is seeking? _______ Yes _______ No

11. Would you re-employ? _______ Yes _______ No

12. Any remarks with regard to questions 1 - 11 above? __________

Signature of person supplying information __________ Date ____________

_______________

I hereby authorize you to release all information regarding my services, character and conduct while in your employ, and you are released from any and all liablility which may result from furnishing such information.


Applicant's Signature		Date