Employer Verification For Cdl Drivers - Premier Logistics
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1Employer Verification for CDL Drivers
FORMER EMPLOYEE INFORMATION AND RELEASE
Name:_____________________________________________________________ Social Security #:______________________
(Please Print)
Hereby Authorize:___________________________________________to release the following requested
(Name of Prior Company)
information to Premier Logistics for the purpose of investigation and qualifying me to drive a commercial motor vehicle as
required by the U.S. Department of Transportation and Federal Motor Carrier Safety Regulations Parts 382, 391, 392
and 49 CFR Part 40. You are hereby released from any and all liability that may result from furnishing such information.
Please respond to this request in a timely manor, it is greatly appreciated.
Signature:_________________________________________________________ Date:________________________________
DO NOT WRITE BELOW THIS LINE
NOTE: Regulations of the Department of Transportation (49 CFR Part 40) requires your company to provide us with information concerning the
named driver's past drug and alcohol test results, including refusals to be tested.
In the past 3 years
has the above named applicant ever:
Yes
No
Tested positive for a controlled substance?
_____
_____
Tested with an alcohol concentration of 0.04 or higher?
_____
_____
Refused to submit to a DOT required drug and/or alcohol test,
including a verified adulterated or substituted result?
_____
_____
Had any other violations of DOT dug and/or alcohol testing regulations?
_____
_____
Had any violations of drug and/or alcohol regulations from previous
employers?
_____
_____
Did a previous employer report a drug and alcohol rule violation to you?
_____
_____
For any YES answer, please provide documentation of the previously named applicants successful completion of DOT return-to-duty
requirements (including follow-up tests).
Work History
Date Hired:________________________ Last Worked:________________________ Position Held:_________________________
Rehire:_______________
Driver Class:
Type:
Truck:
DOT D&A?:
FMCSRs?:
Company: _________
Solo: _________
Tractor-Trailer: _________
Yes: _________
Yes: _________
Lease: _________
Team: _________
Straight Truck: _________
No: _________
No: _________
Own/Op: _________
Student: _________
Other: _________
Other: _________
Other: _________
Eligible for rehire?
Trailers Hauled:
Responsible for maintaining logs:
Areas Driven:
Yes: _________
Flatbed: _________
Yes: _________
OTR: _________
No: _________
Van: _________
No: _________
Regional: _________
Reefer: _________
EOBR: _________
Local: _________
Intermodal: _________
Type:___________
Other: _________
Other: _________
Date
City, State
Description
Fatalities?
# Injuries
Hazmat?
Preventable?
Reason for leaving your employ:
Discharged:__________
Resigned:__________
Laid Off:___________
Other:________________
Your Name:_______________________________________ Title:________________________Telephone:__________________
Signature:_________________________________________________________________
Date:________________________________
Please forward response as indicated as soon as possible:
Fax: 888-959-4470
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