Inquiry to Past Employers

  • Fill and sign the top portion of this form then click on "Submit" to complete your application process.

  • To be filled by employer

    This section will be filled by your previous employer(s). Please scroll down to the bottom of the form and click on "Submit".

    Date From: _______________ Date To: _______________
    No Record of Employment:
    Eligibility for Rehire: Yes No Upon Review
    Other Comments: ____________________

    Contact Information (required by FMCSA)
    Company: _______________
    Address: _______________
    City: __________ St: _____ Zip: _____
    Individual Completing this Form

    Signature of Individual Completing this Form

    Print Name, Title and Date

    Type of Work
    Company Driver
    Owner Operator
    Lease Purchase
    Drove for O/O
    Other __________
    Vehicle Driven
    Tractor Trailer
    Sleeper Cab
    Day Cab
    Straight Truck
    Other __________
    Trailer Pulled
    Dry Van 53'
    Other __________
    Areas Run
    48 states
    Other __________
    Other __________

    Did the applicant have any accidents while in your employ? No Yes | If Yes, please explain
    Yes No
    Yes No
    Yes No
    Yes No
    Cost ($)
    Reason For Leaving
    Resigned With Notice Resigned Without Notice Terminated/Disqualified Laid Off
    Work Record
    No Show
    Quit Under Dispatch
    Unauthorized Equipment Use
    Unauthorized Passenger
    Unauthorized Use of Funds
    Unsatisfactory Safety Record
    Falsified Employment Application
    Equipment/Cargo Loss
    Excessive Complaints
    Late Pickup/Delivery
    Other __________

    Based upon the review of your company's drug and alcohol test record:
    1. Has this individual had an alcohol test with a confirmed breath alcohol concentration of .04 or greater in the past three (3) years? Yes No
    2. Has this individual had a controlled substance test with a positive result in the past three (3) years? Yes No
    3. Has this individual refused (includes a verified adulterated or submitted results) a controlled substance test and/or alcohol test within the past three (3) years? Yes No
    4. Has this individual violated other DOT drug/alcohol regulations? Yes No
    5. Have you received information from a previous employer that this individual violated DOT drug and alcohol regulations? Yes No
    6. Has the individual undertaken or completed a rehabilitation program recommended by a SAP (substance abuse professional) under 382.605? Yes No

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