Employment Verification, Accident Information, And Alcohol Controlled Substance Testing Information Form printable pdf download

P O Box 249, White, GA 30184

800-443-0768

FAX 678-792-5072

Employment Verification, Accident Information, and Alcohol Controlled Substance Testing Information, in

compliance with 40.25g, 391.23b and 390.15b (3 year history)

To Previous Employer:

Application Date:

Applicant Name: X

Social Security # X:

DOB

DL#

State

, do herby authorize my previous employers to release and forward all

information regarding my alcohol and controlled substance testing (If I was employed as a driver) and all other

records of employment including job performance to the above named carrier in connection with my application for

employment. I hereby release my former employers from any and all liability of any type as a result of providing the

above information. I further authorize, without reservation, Kennesaw Transportation, Inc. to contact, and receive

information from DAC Services regarding my previous driving history.

Applicant Signature X

Date

TO BE COMPLETED BY PREVIOUS EMPLOYER

Employment dates: from_________ to_________

from_________ to_________

Did He/She driver for you? __ What type of vehicle? Tractor-Trailer___ Straight Truck___

Other __________________________

What was the reason given for leaving your employ?

___Discharged____ Resignation____ Lay Off____

Is He/She eligible for rehire?

Additional Comments:

____

Please give any/all accident information on this driver, including dates, accident types, preventable/non-

preventable/DOT reportable, etc.

____

______

Alcohol Testing Results (3 Year History)

1. Has this person had an alcohol test with a result of 0.04 or higher alcohol concentration? Yes No

2. Has this person tested positive or adulterated or substituted a test specimen for controlled substances? Yes No

3. Has this person refused to submit to a post accident, random, reasonable suspicion, or follow-up alcohol or

controlled substance test? Yes No

4. Has this person committed other violations of Subpart B of Part 382 or part 40? Yes No

5. 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-duty and follow-up tests? Yes No

(If yes, please send documentation back with this form.)

6. For a driver who successfully completed a 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 refuse to be

tested? Yes No

Company Representative Signature _________________________ Title ______________________ Date __________

Employment Verification, Accident Information, And Alcohol Controlled Substance Testing Information Form

Related Articles

Related forms

Related Categories