Employer Verification for CDL Drivers

FORMER EMPLOYEE INFORMATION AND RELEASE

DRIVER: SSN #
(please print)

Herby authorize to release the following requested
(Name of Prior Company)

Information to the CITY OF DALLAS 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, and 49 CFR Part 40. You are hereby released from any and all liability that may result from furnishing such information. Your quick response to this request will be greatly appreciated.

Signature Date

FORMER EMPLOYEE WORK HISTORY
DRIVER: SSN: DATE:
COMPANY: ATTN:
Period of Service Detail
Start Date: End Date: Miles / Week: Hours/ Week:
Position Held:
Reason(s) for Leaving:

Eligible for rehire? Yes No

Driver Class: Type: Truck: Subject to FMCSRs? Subject to DOT D&A?
Company Solo Tractor-Trailer Yes Yes
Lease Team Straight Truck No No
Own/Op Student Tanker
Other Other Other
Load Hauled: Trailer Length
Other

ACCIDENT HISTORY – TO BE COMPLETED BY PREVIOUS COMPANY/ VENDOR:
Complete the following for any accidents involving the driver. If NO accidents, check this box

Date
(mm/dd/yyyy) / Check if Preventable / No. of injuries / No. of Fatalities / Location
(City, State) or (Prov) / Description

Note: If more than three accidents, please attach additional sheet(s)

ALOCOHL AND DRUG SECTION
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 three years prior to the date of the employee’s signature (on the release), for DOT-regulated testing:

·  Did the employee have alcohol tests with a result of 0.04 or higher? Yes No

·  Did the employee have verified positive drug tests? Yes No

·  Did the employee refuse to be tested? Yes No

·  Did the employee have other violations of DOT agency drug and alcohol testing regulations? Yes No

·  Did a previous employer report a drug and alcohol rule violation to you? Yes No

·  If you answered “yes” to any of the above items, did the employee Yes No N/A
complete the return –to-duty process?

Note: YES answer, please provide documentation of the previously named applicant’s successful completion of DOT Return –To –Duty requirements (including follow-up test).

Your Name Title Telephone
Your Signature Date

Please forward response as indicated as soon as possible
Thank You, any question please contact: at (214)

MAIL: CITY OF DALLAS 1500 Marilla Street 6AN Dallas, Texas 75201
FAX: (214)

ORM-FRM-604 Revision 2 5/17/16 Page 1 of 2