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PREVIOUS SAFETY PERFORMANCE HISTORY ONE RESPONSE TO BE COMPLETED BY EACH PREVIOUS EMPLOYER IN THE LAST TEN YEARS Pursuant to a request for Previous Safety Performance History Dated; . This response being provided to the Prospective Contractor noted below in compliance with the Department of Transportation Regulations, 9l.23(g)(l)and40.32l(b). Corrected Copy, Replaced Response Dated: _ Name of Previous Employee or Contractor: Q DOT Regulated Driver Social Security No.: Date of Birth: D Non-DOT Regulated Driver Employed From to as PREVIOUS EMPLOYER OR CONTRACTOR INFORMATION Company Name: Phone Number: Contact Name: Email: Street: City, State, Zip: PROSPECTIVE CONTRACTOR INFORMATION Company Name: THIS FORM WAS (check appropriate box) Attention: Q Mailed,Date: Street: Q Faxed Date: City, State, Zip a Emailed Date Phone Number a Relayed by Phone, Date Name of Person Contacted SAFETY PERFORMANCE HISTORY QThere is no safety performance history to report. Driver operated a: UStraight Truck QTractorTruck Q Tractor- Semitrailer QBus Q Cargo Tank QDoublcs/TriplcsQ Other (Specify) QDriver did not operate a motor vehicle/ Reason for leaving emply or terminating the contractor relationship: ^Discharged ^Resignation QLay Off QMilitary Duty ACCIDENTS: Date 1



No. of Injuries

No of Fatalities

Hazard Material Spill

3 QNo accident register data for this driver. QEnclosed is other accident information pursuant to the employers's or contractor's internal policies tor retaining minor accident information (391.23(d)(2)(ii)).

DRUG/ALCOHOL TESTING: ^Prospective contractor did not provide signed release from driver (40.32 l(b)). Therefore drug/alcohol information cannot be provided Under DOT drug and alcohol testing requirements for the past 2 years: Yes No 1 This person was employed in a safety-sensitive function that required alcohol and controlled substances Q Q · testing specified by 49 CFR Part 0 (if NO, skip this section) 2 This person had an alcohol test with a result of 0.04 or higher alcohol concentration. Q Q 3 This person tested positive or adulterated or substituted a test specimen for controlled substances Q Q 4 This person refused to submit to a post-accident, random, reasonable suspicion, or follow-up alcohol U Q · controlled substance test. 5 This person committed other violations of Subpart B of Part 382, or Part 40 Q Q 6 This person violated a DOT drug and alcohol regulation and completed a SAP-prescribed rehabilitation program in our employ or contract, including return-to-duty and follow-up tests. If yes, documentation is enclosed. Q Q 7 This person, after successfully completing a SAP's rehabilitation referral, remained in our employ but subsequently had an alcohol test result of 0.04 or greater, a verified positive drug test, or refused to be

tested. a a

In providing this information, any drug or alcohol testing information obtained from prevous employers or contractors under 40.25 or other applicable DOT Regulations is included. Any other remarks:




FOR PREVIOUS EMPLOYER'S OR CONTRACTOR'S RECORD-KEEP A RECORD OF EACH REQUEST AND THE RESPONSE FOR ONE YEAR, INCLUDING THE DATE, THE PARTY TO WHOM IT WAS RELEASED, AND A SUMMARY IDENTIFYING WHAT WAS PROVIDED Authorization for Previous Employer or Contractor to Release Employment Information I hereby authorize the release of all information required by 49CFR 391.23 7 49CFR 382.413. I have been informed that previous employers or contractors shall be contacted to complete a background investigation.

Printed Name of Prospective Contractor

Signature of Prospective Contractor



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