Request For Previous Employment Verification
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1On The Spot Staffing
12118 Jones Rd, Suite D-146 Houston, TX. 77070
Phone: 844-782-3235 Fax: 844-7823329 Email:
REQUEST FOR PREVIOUS EMPLOYMENT VERIFICATION
Section 1 : TO BE COMPLETED BY PROSPETIVE EMPLOYEE
I, (Print Name) ______________________________________________
______/_____/________
First
M. I.
Last
Social Security Number
Previous Employer _______________________________________________________________________________________
Address __________________________________________________________Tel.: __________________________________
City, State, Zip _____________________________________________________ Fax: __________________________________
You may release and forward information requested by Section 2.1-11 of this document concerning my alcohol and controlled substance
testing records and employment information.
Applicant Signature: __________________________________________________________________ Date ___________________________
Section 2: TO BE COMPLETED BY PREVIOUS EMPLOYER
Complete this Section as required by FMCSR Part 382
1.
Has this person tested positive for a controlled substance in the last 3 years?
YES or NO
2.
Has this person had an alcohol test with a Breath Alcohol Concentration 0.04
Or higher in the last 3 years.
YES or NO
3.
Has this person ever refused a required test for drugs or alcohol
YES or NO
4.
Has any previous employer reported failure and/or refusal of Drug/Alcohol
tests?
YES or NO
If yes to any of the above questions, please give SAP’s (Substance Abuse Professional) name, address and phone number
Name ________________________________________________________________________________________________________________________________
Address_____________________________________________________________________________________ Tel. ______________________________________
1.
Employed from (mm/yy) __________________ To (mm/yy) _________________
2.
Did he/she drive a motor vehicle for you?
YES or NO
3.
Vehicles Driven: Straight Truck Tractor-Semitrailer Bus Van Flatbed Reefer Other
If other, Please explain: ________________________________________________________________________
4.
Was he/she a safe and efficient driver?
YES or
NO
YES or
NO
5.
Was his/her general conduct satisfactory?
6.
Was driver involved in any chargeable accident?
YES or
NO
7.
Eligible for rehire?
YES or
NO
YES
or NO
8.
Eligible for rehire?
Section 2 completed by: _________________________________________________ Date _________________
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