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BSCMP*** – v** – ****-**-** Page * of *
FOR DOT POSITIONS: DOT EMPLOYMENT & SAFETY HISTORY CHECK
DEPARTMENT OF TRANSPORTATION (DOT) DRUG/ALCOHOL DISCLOSURE AND AUTHORIZATION I have made application to the hiring Company/Employer listed below for a safety-sensitive function under DOT regulations. Pursuant to 49 CFR Part 40.25 I am hereby requesting that your entity provide the information requested below to Employment Background Investigations, Inc. (EBI), PO Box 629, Owings Mills, MD 21117, 1-800-***-****, in its capacity as the CTPA for the hiring Company/Employer whose name appears below. PLEASE NOTE, THE FOLLOWING QUESTIONS WILL NEED TO BE ANSWERED BY YOUR PREVIOUS DOT EMPLOYER: INSTRUCTION TO APPLICANT:
PLEASE COMPLETE ALL OF THE SECTIONS BELOW. IF MORE THAN ONE PREVIOUS DOT EMPLOYER, USE A SEPARATE CONFIDENTIAL REQUEST FORM FOR EACH EMPLOYER THAT YOU HAVE WORKED FOR IN THE PREVIOUS 3 YEARS, IF YOUR HIRING EMPLOYER IS AN FMCSA COVERED EMPLOYER (2 years for all other DOT Agencies: FAA, PHMSA, USCG, FTA or FRA). Previous DOT
Employer Name
Position Address Supervisor
Telephone
Number
Fax Start
Date
End
Date
INSTRUCTIONS FOR PREVIOUS EMPLOYER: PLEASE COMPLETE THE FOLLOWING 7 QUESTIONS (if applicant is seeking an FMCSA covered position then complete for the past 3 years ; For all other DOT agencies complete for the previous 2 years): 1. Was he/she employed in a DOT safety-sensitive function? Yes No a. If yes, what position? 2. Did the employee have alcohol tests with a result of 0.04 or higher? Yes No 3. Did the employee have verified positive drug tests? Yes No 4. Did the employee refuse to be tested? Yes No 5. Did the employee have other violations of DOT agency drug and alcohol testing regulations? Yes No 6. Did a previous employer report a drug and alcohol rule violation to you? Yes No 7. If you aŶsǁered ͞ yes͟ to aŶy of the aďoǀe iteŵs, did the eŵployee Đoŵplete the returŶ-to-duty process? Yes No Note: If you aŶsǁered ͞ yes͟ to iteŵ 6, you ŵust proǀide the preǀious eŵployer’s report. If you aŶsǁered ͞ yes͟ to iteŵ 7, you must also transmit the appropriate return-to-duty documentation (e.g., SAP report(s), follow-up testing record). 49 CFR Part 40.25 mandates that previous employers must immediately provide information regarding any violations found. Safety Performance History: After 10/29/03 while operating a CMV, was the employee involved in a driving accident where there were fatalities, bodily injuries that required treatment away from the accident site, and/or one or more vehicles having to be towed away from the accident scene? Yes No If yes, provide the following details for every CMV accident, as defined by the Federal Motor Carrier Safety Administration (FMCSA) in 49 CFR Part 390.5 that the applicant was involved in while in your employ during the three years preceding this request. Attach additional pages if more space is needed. GRAND FORCE, ND
10/03/2018
06/03/2017
5520- 32ND AVE SOUTH J&M LINES
PRO TRANSPORTATION EPPS TRANSPORT
BSCMP002 – v02 – 2017-08-11 Page 2 of 2
APPLICANT CONSENT FOR RELEASE AUTHORIZATION
By my signature below I hereby authorize release of information from my Department of Transportation Regulated Drug and Alcohol Testing Records by my previous employer (listed above) to Employment Backgrounds Investigations Inc.
(EBI), in its capacity as the CTPA for the hiring Company/Employer whose name appears below. This release is in accordance with DOT regulations 49 CFR part 40, Section 40.25. I understand that information to be released is limited to the items ƌeƋuested above undeƌ the ͞ INSTRUCTIONS FOR PREVIOUS EMPLOYERS͟ . Authorization of this release will expire once the requested information has been sent to the hiring Company/Employer or its designated CTPA. This authorization may not be used to provide information to any other persons. I certify all former DOT employer information provided by me is correct. Hiring Company / Employer: Applicant Name: Applicant SSN or ID#: Applicant Signature: Date: 06/03/2021
XXX-XX-2091
TOMMY JUNIOR MARTIN
SAVAGE
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