Request and Consent for Information from Previous Employer

By signing below, I authorize my former employer listed hereafter to release the information requested in regard to my employment and controlled substance testing to American Lighthouse Transportation as dictated by the Federal Motor Carrier Safety Regulations. As my former, employer, I release you from any liability which might be the result of providing this informtion.

(Please Print) Driver's Name: *

Social Security #:

Driver's Signature:

Date:

Information Requested From

Applicant: STOP HERE

Previous Employer's Name:

Contact:

Address:

City:

State/Province:

Zip:

Phone:

To Whom It May Concern:
The person named above has, while seeking employment with this company as stated that he/she held a position with your company as from to . Your time in answering the questions in the form below is greatly appreciated. Be assured that you provide this information in confidence, to assist in this company's hiring process. Thank you for your assistance.

Signature and Title of Company Representative

Please answer the following questions
During what period of time was this individual employed with you?
From: - - To: - -

Did the individual operate a motor vehicle?

If so, what type?

Trucktor-Trailer
Straight Truck
Other (Please Explain)

How would you describe his/her conduct?

Good
Fair
Poor

Did the individual perform their duties safely?

At what wage/salary was he/she employed?

Under what circumstances did the individual leave your employ?

In the past two years, did this persons test positive for any controlled substances?

If so, please list the name and address of the Professional Testing Organization that perofrmed the test.

Attach File:

Request and Consent for Information from Previous Employer

Information Requested From

Applicant: STOP HERE

American Lighthouse Transportation – Delivering Confidence with Every Load