FOURTH LAST EMPLOYER COMPANY NAME: ADDRESS: : ZIP: FAX: EMAIL: REASON FOR SUPERVISOR NAME: LEAVING? DESCRIPTION FROM: TO: YES NO Were you subject to controlled substances and alcohol testing specified by 49 Part 40 during this period? YES NO *Was this job subject to FMCSA Regulations? **ACCOUNT FOR PERIOD BETWEEN JOBS Include dates (month/year) and – reason: FIFTH LAST EMPLOYER COMPANY NAME: ADDRESS: : STATE: ZIP: PHONE: FAX: EMAIL: REASON FOR SUPERVISOR NAME: LEAVING? DESCRIPTION FROM: TO: YES NO Were you subject to controlled substances and alcohol testing specified by 49 Part 40 during this period? YES NO *Was this job subject to FMCSA Regulations? **ACCOUNT FOR PERIOD BETWEEN JOBS Include dates (month/year) and – reason: SIXTH LAST EMPLOYER COMPANY NAME: ADDRESS: : STATE: ZIP: PHONE: FAX: REASON FOR SUPERVISOR NAME: LEAVING? DESCRIPTION FROM: TO: YES NO Were you subject to controlled substances and alcohol testing specified by 49 Part 40 during this period? YES NO *Was this job subject to Regulations? **ACCOUNT FOR PERIOD BETWEEN JOBS Include dates (month/year) and – reason: * The Federal Carrier Safety Regulations apply to anyone operating a motor vehicle on a highway in interstate commerce to transport passengers or property when the vehicle: 1) weighs or has a GVWR of 10,001 pounds or more, 2) is designed or used to transport 9 or more passengers, or 3) is of any size and is used to transport hazardous materials in a quantity requiring placarding. **Any gaps in employment MANDATORY USE FOR ALL ACCOUNT HOLDERS NOTICE: This form is made available to monthly account holders by NICT on behalf of the U.S. Department of Transportation, Federal Motor Carrier Safety Administration (FMCSA). Account holders are required by federal law to obtain an Applicant’s written or electronic consent prior to accessing the Applicant’s PSP report. Further, account holders are required by FMCSA to use the language provided in paragraphs 1-4 of this document to obtain an Applicant’s consent. The language must be used in whole, exactly as provided. The language may be
FOURTH LAST EMPLOYER COMPANY NAME: ADDRESS: : ZIP: FAX: EMAIL: SUPERVISOR NAME: REASON FOR LEAVING? DESCRIPTION FROM: TO: Were you subject to controlled substances and alcohol testing specified by 49 Part 40 during this period? YES NO *Was this job subject to FMCSA Regulations? YES NO **ACCOUNT FOR PERIOD BETWEEN JOBS – Include dates (month/year) and reason: FIFTH LAST EMPLOYER COMPANY NAME: ADDRESS: : STATE: ZIP: PHONE: FAX: EMAIL: SUPERVISOR NAME: REASON FOR LEAVING? DESCRIPTION FROM: TO: Were you subject to controlled substances and alcohol testing specified by 49 Part 40 during this period? YES NO *Was this job subject to FMCSA Regulations? YES NO **ACCOUNT FOR PERIOD BETWEEN JOBS – Include dates (month/year) and reason: SIXTH LAST EMPLOYER COMPANY NAME: ADDRESS: : STATE: ZIP: PHONE: FAX: SUPERVISOR NAME: REASON FOR LEAVING? DESCRIPTION FROM: TO: Were you subject to controlled substances and alcohol testing specified by 49 Part 40 during this period? YES NO *Was this job subject to Regulations? YES NO **ACCOUNT FOR PERIOD BETWEEN JOBS – Include dates (month/year) and reason: * The Federal Carrier Safety Regulations apply to anyone operating a motor vehicle on a highway in interstate commerce to transport passengers or property when the vehicle: 1) weighs or has a GVWR of 10,001 pounds or more, 2) is designed or used to transport 9 or more passengers, or 3) is of any size and is used to transport hazardous materials in a quantity requiring placarding. **Any gaps in employment MANDATORY USE FOR ALL ACCOUNT HOLDERS NOTICE: This form is made available to monthly account holders by NICT on behalf of the U.S. Department of Transportation, Federal Motor Carrier Safety Administration (FMCSA). Account holders are required by federal law to obtain an Applicant’s written or electronic consent prior to accessing the Applicant’s PSP report. Further, account holders are required by FMCSA to use the language provided in paragraphs 1-4 of this document to obtain an Applicant’s consent. The language must be used in whole, exactly as provided. The language may be
DRIVER-FILE-MERGE-SYSTEM-1.docx