RESOURCES

SAFETY RECORD REQUEST

Request for General and Safety Performance History Records from
Previous Employer

By filling out this form you release the following information to H&H Express Inc. and its ASSIGNEES for the purpose of investigations as required by Parts 390, 391, 382, and 40 of the Federal Motor Carrier Safety Regulations. This includes the release of all safety performance history information, as well as specific information requested below in reference to drug and alcohol testing within the last three years, including information you may have from previous employers. You are released from any and all liability, which may result from furnishing such information. Thank you for your cooperation.

TO BE COMPLETED BY APPLICANT

Name:
Date:
Social Security Number:
Previous Employer Name:
Previous Employer Address:
Phone:
Fax:
Position Title:
Employment Timeframe (M/Y-M/Y):
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TO BE COMPLETED BY PREVIOUS EMPLOYER

Employer Name:
Employer Address:
Employer Phone:
Employer Fax:
Previous Employees Job Title:
Did he/she drive motor vehicles for you?	----YesNo
If yes, what type?	----Straight TruckTractor-Semi TrailerBusTankerDouble/TripleOther
If other, please specify:
Reason for leaving employment:	----DischargedResignationLay OffMilitary Duty
Safe and efficient driver?	----YesNo
General conduct satisfactory?	----YesNo
Accidents: any accidents registered (390.15 (b) that involved applicant:
Please provide information concerning any other accident involving the applicant that were reported to government agencies or insurers or retained under internal company policies:
Any other remarks:
* Drug and Alcohol History: If employee was subject to DOT testing requirements, did the person named above:	Have an alcohol test with a result of 0.04 or higher alcohol concentration?  Test positive or adulterate or substitute a test specimen for controlled substances?  Refuse to submit to post accident, random, reasonable suspicion, or follow-up alcohol or controlled substance test?  Has this person committed other violations of subpart B of part 382 or part 40?
If this person has violated a DOT drug and alcohol regulation, did this person complete a SAP prescribed rehabilitation program in your employ, including return-to-work and follow-up tests? If yes, please send documentation.	----YesNoNever required to attend rehab
For a driver who successfully completed SAP's rehabilitation referral and remained in your employment, did this driver subsequently have an alcohol test result of 0.04 or greater, a verified positive drug test, or refused to be tested?	----YesNo
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* If answering the Drug and Alcohol History questions, include any required DOT drug and alcohol testing information obtained from previous employers in the previous 3 years prior to the application date.

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