Name of Company: __________________________________ Phone (___) ______________ Fax:(___)______________
To Former Employer: Please provide the following information about this applicant to the representative listed at the bottom of this form. Please fax this form to the following confidential fax 727-489-183.
TO BE COMPLETED BY PREVIOUS EMPLOYER OR MOTOR CARRIER
Company address: Street ________________________________________ City _____________________________ State __________ Zip ___________
Please check appropriate box: ( )DOT Regulated Driver or ( )Non-DOT Regulated Driver
Period of Employment: From__________________________ To __________________________
Position Held _______________
Driver Operated: ( ) Local (inside 100 air mile radius) ( ) Over the Road ( )All 48 states ( ) Regional ___________
Driver Type: ( )Company Driver ( ) Owner-Operator ( ) Driver for Own-Operator
Status: ( ) Full ( )Part Time
Driver Operated a: ( ) 53’ Tractor Trailer ( ) Straight Truck ( )Bus ( ) Other ______________________
List states in which applicant drove regularly: _____________________
List type of commodities applicant hauled: ____________
Accidents: ( ) There is NO accident register data for this driver ( ) Attached is other accident information
Date Description Location #of Injuries #of Fatalities Preventable?
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
Tickets ( ) Yes ( ) No If yes, please describe _________________________________________________
______________________________________________________________________________________________
Reason for leaving your company? ( )Resigned ( ) Discharged ( )Lay Off ( ) Leave of Absence ( ) Other _________________
Is applicant eligible for rehire: ( ) Yes ( ) No If no, please explain why: ______________________________________________
Are your tractors leased to anyone? ( ) Yes ( ) No If yes, who? ____________________________________________________
What companies did applicant show working for prior to your company?_____________________________________________________________________________________________________________________________________________________
Alcohol and Controlled Substance Test Results - this information is required if employed with your company within the last 3 years or if applicant tested positive or refused to be tested within the last 5 years.
1. Was this person in a safety-sensitive function that required alcohol and controlled substances testing specified by 49 CFR Part 40? (if NO, skip next questions) ( ) Yes ( ) No
2. Were there any positive or adulterated or substituted results for a controlled substance test? ( ) Yes ( ) No
3. Were there any alcohol tests with a result of .02 or higher alcohol concentration? ( )Yes ( ) No
4. Were there any alcohol or controlled substance test refusals? ( ) Yes ( )No
5. Were there any violations of other DOT drug and alcohol regulations? ( ) Yes ( ) No
6. Do you have information from previous employers that this individual violated DOT drug and/or alcohol regulations? ( ) Yes ( ) No
7. If there was a drug/alcohol violation, did the applicant complete a substance abuse rehabilitation program? ( ) Yes ( ) No
Completed by: Name___________________________________Title_______________________________Date___________
Florian LLC Representative requesting information: Sarah Florian, Safety Manager
TO: Drug Records Dept From: Sarah Florian, Safety Manager