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RESOURCES

SAFETY RECORD REQUEST

Request for General and Safety Performance History Records from
Previous Employer

By filling out this form you release the following information to H&H Express Inc. and its ASSIGNEES for the purpose of investigations as required by Parts 390, 391, 382, and 40 of the Federal Motor Carrier Safety Regulations. This includes the release of all safety performance history information, as well as specific information requested below in reference to drug and alcohol testing within the last three years, including information you may have from previous employers. You are released from any and all liability, which may result from furnishing such information. Thank you for your cooperation.

TO BE COMPLETED BY APPLICANT


 
 

TO BE COMPLETED BY PREVIOUS EMPLOYER


 Have an alcohol test with a result of 0.04 or higher alcohol concentration?
 Test positive or adulterate or substitute a test specimen for controlled substances?
 Refuse to submit to post accident, random, reasonable suspicion, or follow-up alcohol or controlled substance test?
 Has this person committed other violations of subpart B of part 382 or part 40?
 
 

* If answering the Drug and Alcohol History questions, include any required DOT drug and alcohol testing information obtained from previous employers in the previous 3 years prior to the application date.

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