From Previous Employer

As required by 49 CFR Parts 382.413, 390, 391, 23, and 40.25b of the Motor Carrier Safety Regulations


Mr./Ms. ,

SS# has made application to our company for a position as a and states being employed by you from to .

Will you kindly reply to the inquiry below respecting this applicant? For Your convenience, please fax your response to (800) 526-3128. Thank you.

  1. What are the dates of employment with your company? to

  2. What kind(s) of work did the applicant do?

  3. Did the applicant drive motor vehicles for you?

  4. Did the applicant pull:

  5. Approximately how many miles a month did the applicant run?

  6. In how many states did the applicant operate?

  7. Provide detail of Cargo Claims/damage and number of late deliveries:

  8. Describe other violation of company policy or procedures:

  9. For the preceding 3 years, please give details of DOT recordable accidents (description, dates, location, injuries, hazmat and fatalities):

  10. Give descriptions, dates, whether preventable or not, of other vehicle accidents in which the applicant was involved:

  11. Please answer the following questions concerning alcohol and controlled substance testing during the past 3 years.

    • Did the applicant refuse alcohol or drug testing? This includes verified adulterated or substituted test results?

    • Did the applicant have a positive controlled substance test result?

    • Did the applicant have any alcohol test with a concentration result of 0.04 or greater?

    • Did the applicant have a positive pre-employment controlled substance test or an alcohol test with a concentration of 0.04 or greater?

    • If required, did the applicant complete a substance abuse rehabilitation program?

    • Did the applicant have any other violations of DOT agency drug and alcohol regulations?

  12. Reason for leaving your employ:

  13. Eligible for Rehire:

By: Date:
(Signature of person supplying information)

You are hereby authorized to give Hornady Transportation, LLC. all information regarding my services, safety performance history, accidents, character and conduct as well as my DOT & non-DOT alcohol and controlled substance test results while in your employ and/or information about any drug or alcohol test result obtained from previous employers. Moreover, you are released from any and all liability which may result from furnishing such information.

I understand drivers with Department of Transportation regulated employment have the right to review Safety performance history information provided by regulated previous employers; have errors in that information corrected and have employers to re-send corrected information to prospective employers and to have a rebuttal statement attached to alleged erroneous information if the previous employer and driver cannot agree on the accuracy of the information.

I authorize Hornady Transportation, LLC. to access HireRight and the FMCSA Pre-Employment Screening Program (PSP) to seek information regarding my commercial driving safety record and information regarding my safety inspection history. If based on the PSP a decision to not hire you is made, you will be sent a written summary of your rights under the Fair Credit Reporting Act. Moreover, with your written request to Hornady Transportation, LLC, you will be provided a copy of the report upon which its decision was based.

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