SECTION 2: Previous Employer Complete the information in this section; sign, date and return to the Prospective Employer. Section 2 TO BE COMPLETED BY PREVIOUS EMPLOYER ACCIDENT HISTORY The applicant named in Section 1 above was employed by ☐ ☐ us. Yes No Employed as From (M/Y) / To (M/Y) / Did he/she drive a motor vehicle for If yes, what type of ☐ ☐ you? Yes No vehicle? Why did he/she leave your Would you ☐ ☐ ☐ ☐ ☐ Company? Quit Terminated Laid Off Yes No Complete the following for any accidents included on your DOT Accident Register (§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. Number of Date Location Number of Injuries Fatalities 1. / / 2. / / 3. / / Please provide information concerning any other accidents involving the applicant that were reported to government agencies or insurers under internal company policies: DRUG AND ALCOHOL HISTORY ☐ If the driver was not subject to US DOT testing requirements while employed by you, please check here sign, and return. Driver was subject to US DOT testing requirements from to . YES NO 1. Has this person had an alcohol test with a result of 0.04 or higher alcohol concentrate? ☐ ☐ Has this person tested positive or adulterated or substituted a test specimen for controlled ☐ ☐ 2. substances? ☐ ☐ 3. Has this person refused to submit to a post-accident, random, reasonable suspicion, or follow-up alcohol or controlled substance test? ☐ ☐ 4. Has this person committed other violations of Subpart B of Part 382, or Part 40? ☐ ☐ 5. If this person has violated a DOT drug and alcohol regulation, did this person fail to undertake or complete a program prescribed by a Substance Abuse Professional (SAP) in your employ? If no, please send documentation back with this form. If you are unsure, check yes. ☐ ☐ 6. For a driver who successfully completed SAP’s rehabilitation referral and remained in your employ, did this driver subsequently have an alcohol test result of 0.04 or greater, a verified positive drug test, or refused to be tested?
SECTION 2: Previous Employer Complete the information in this section; sign, date and return to the Prospective Employer. Section 2 TO BE COMPLETED BY PREVIOUS EMPLOYER ACCIDENT HISTORY The applicant named in Section 1 above was employed by us. Yes ☐ No ☐ Employed as From (M/Y) / To (M/Y) / Did he/she drive a motor vehicle for you? Yes ☐ No ☐ If yes, what type of vehicle? Why did he/she leave your Company? Quit ☐ Terminated ☐ Laid Off ☐ Would you Yes ☐ No ☐ Complete the following for any accidents included on your DOT Accident Register (§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 1. / / 2. / / 3. / / Please provide information concerning any other accidents involving the applicant that were reported to government agencies or insurers under internal company policies: DRUG AND ALCOHOL HISTORY If the driver was not subject to US DOT testing requirements while employed by you, please check here ☐ sign, and return. Driver was subject to US DOT testing requirements from to . YES NO 1. Has this person had an alcohol test with a result of 0.04 or higher alcohol concentrate? ☐ ☐ 2. Has this person tested positive or adulterated or substituted a test specimen for controlled substances? ☐ ☐ 3. Has this person refused to submit to a post-accident, random, reasonable suspicion, or follow-up alcohol or controlled substance test? ☐ ☐ 4. Has this person committed other violations of Subpart B of Part 382, or Part 40? ☐ ☐ 5. If this person has violated a DOT drug and alcohol regulation, did this person fail to undertake or complete a program prescribed by a Substance Abuse Professional (SAP) in your employ? If no, please send documentation back with this form. If you are unsure, check yes. ☐ ☐ 6. For a driver who successfully completed SAP’s rehabilitation referral and remained in your employ, did this driver subsequently have an alcohol test result of 0.04 or greater, a verified positive drug test, or refused to be tested? ☐ ☐