Supplemental CFR Request


 

 

 

Supplemental CFR Request

1. Company Information 

It is the policy of the company listed above to provide equal employment opportunities to all applicants and employees without regard to any legally protected status such as race, color, religion, gender, sexual orientation, national origin, age, disability or veteran status.

2. Applicant Information

Name:

Current Address:

Email Address: 

Day Time Telephone number:

Cellular Telephone Number:

 For those drivers applying to operate a commercial motor vehicle as defined by part 383 of this subchapter, a list of the names and addresses of the applicant's employers during the 7-year period preceding the 3 years contained in paragraph (b)(10) of this section for which the applicant was an operator of a commercial motor vehicle, together with the dates of employment and the reasons for leaving such employment:

3. Previous Employment

DRIVER Applicants that desire to drive in intrastate/interstate commerce must provide the following information on all employers during the previous three years. You must give the same information for all employers you have driven a commercial motor vehicle for the seven years prior to the initial three years (total of ten years employment record).

#1 First Previous Employer or Current employer Information:

Years with this engagement:

Were you subject to the FMCSR's (drug and alcohol testing) While employed by this previous employer?

Job was designated as a safety sensitive function in any DOT regulated mode subject to alcohol and controlled substances testing requirements as required by 49 CFR part 40?

Supervisors Name:

Would you like to provide a FAX number, Email address or both:

Company Fax #:

Supervisor or HR Email:

Company Phone Number:

Company Address:

Job Duties:

Reason for Leaving:

Beginning Date of Employment:

Ending Date of Employment:

Do you intend to remain employed with this employer:

Rate of Pay (Per Hour):

Does this Complete your ten year history?

#2 Previous Employer Information:

Years with this engagement:

Were you subject to the FMCSR's (drug and alcohol testing) While employed by this previous employer?

Job was designated as a safety sensitive function in any DOT regulated mode subject to alcohol and controlled substances testing requirements as required by 49 CFR part 40?

Supervisors Name:

Would you like to provide a FAX number, Email address or both:

Company Fax #:

Supervisor or HR Email:

Company Phone Number:

Company Address:

Job Duties:

Reason for Leaving:

Beginning Date of Employment:

Ending Date of Employment:

Do you intend to remain employed with this employer:

Rate of Pay (Per Hour):

Does this Complete your ten year history?

#3 Previous Employer Information:

Years with this engagement:

Were you subject to the FMCSR's (drug and alcohol testing) While employed by this previous employer?

Job was designated as a safety sensitive function in any DOT regulated mode subject to alcohol and controlled substances testing requirements as required by 49 CFR part 40?

Supervisors Name:

Would you like to provide a FAX number, Email address or both:

Company Fax #:

Supervisor or HR Email:

Company Phone Number:

Company Address:

Job Duties:

Reason for Leaving:

Beginning Date of Employment:

Ending Date of Employment:

Do you intend to remain employed with this employer:

Rate of Pay (Per Hour):

Does this Complete your ten year history?

#4 Previous Employer Information:

Years with this engagement:

Were you subject to the FMCSR's (drug and alcohol testing) While employed by this previous employer?

Job was designated as a safety sensitive function in any DOT regulated mode subject to alcohol and controlled substances testing requirements as required by 49 CFR part 40?

Supervisors Name:

Would you like to provide a FAX number, Email address or both:

Supervisor or HR Email:

Company Fax #:

Company Phone Number:

Company Address:

Job Duties:

Reason for Leaving:

Beginning Date of Employment:

Ending Date of Employment:

Do you intend to remain employed with this employer:

Rate of Pay (Per Hour):

Does this Complete your ten year history?

Did you drive any commercial vehicles for any company in the last ten years that you were unable to list above?  

Did you drive any Commercial Vehicles for any company  in the last ten years that you were unable to list above? 

Please provide any other information that you believe should be considered, including whether you are bound by any agreement with any current employer:

 

4. Notice to All Applicants:

I certify that the information provided on this application is truthful and accurate. I understand that providing false or misleading information will be the basis for rejection of my application, or if employment commences, immediate termination: 

I authorize to contact former employers and educational organizations regarding my employment and education. I authorize my former employers and educational organizations to fully and freely communicate information regarding my previous employment, attendance, and grades. I authorize those persons designated as references to fully and freely communicate information regarding my previous employment and education: 

 

Date of application:

 

 

 

Request/Consent for previous employment 49 CFR Part 40 Drug and Alcohol #5

Applicants that desire to drive in intrastate/interstate commerce must provide the following information on ALL EMPLOYERS during the previous three years. Additionally, you must provide the same information for all employers you HAVE DRIVEN A COMMERCIAL MOTOR VEHICLE for for the seven years prior to the initial three years (total of ten years employment record for CDL drivers)

SECTION 1: To be completed by the applicant for submission to previous employer. All fields are required.

Requesting Company Name:

Applicant Name:

Applicant Address:

Applicant Telephone:

Applicant Email Address:

Social Security Number:

Previous Employer:

Previous Employer Manager:

Previous Employer Address:

Previous Employer Telephone:

Previous Employer FAX:  

Previous Employer Email:

Employed From:

Employed to (enter current date if still employed):

Do you intend to remain employed with this employer:

Final hourly rate of Pay:

Reason for Leaving:

Were you subject to the Federal Motor Carrier Safety Regulations (FMCSRs) While employed by this employer?

Was the previous job position designated as a safety sensitive function in any DOT regulated mode, subject to alcohol and controlled substances testing requirements as required by 49 CFR Part 49?

SECTION 2: To be completed by the applicant. As required by CFR 49 Part 391.23(c), we are forwarding this inquiry on the above named person who has made application to the above referenced company for employment as a commercial vehicle operator or mechanic. We respectfully request that you reply to this inquiry to the extent that your company policy allows, regarding this applicant. The applicant has signed the attached liability release for your records.

RELEASE of INFORMATION Form-49 CFR Part 40 Drug and Alcohol Testing:  I hereby authorize release of information from my Department of Transportation regulated drug and alcohol testing records by my  previous employer listed in Section 1, to the employer listed in the header section. This release is in accordance with DOT Regulation 49 CFR Part 40,  Section 40.25. I understand that information to be released in Section 3 by my previous employer is limited to the following DOT regulated testing items.

Items to be released: Alcohol Tests with a result of 0.04 or higher, Verified positive drug tests, Refusals to be tested, Other violations of DOT agency drug and alcohol testing regulations, Information obtained from previous employers of a drug and alcohol rule violations, and Documentation, if any, of completion of the return-to-duty process following a rule violation.

SECTION 3: To be completed by previous Employer and transmitted by mail, please fax or email to the new employer. Fax, Mail or Email with information listed at top of page.

Did the employee have alcohol tests with a drug result of 0.04 or higher?                            

Yes        No

Did the employee have verified positive drug results?                                                

Yes        No

Did the employee refuse to be tested?                                                                

Yes        No

Did the employee have other violations of DOT agency drug and alcohol testing rules?                

Yes        No

Did a previous employer report a drug or alcohol rule violation to you?                            

Yes        No

If you answered yes to any of the above items, did the employee complete the return-to-duty process?

Yes       No

NOTE:  If you answered yes to item 5, you MUST provide the previous employer's report. If you answered "yes" to item 6, you must also transmit the appropriate return-to-duty documentation

(e.g., SAP report(s), follow up testing record).

SECTION 4: To be completed by previous Employer

Employee was Employed From:   _________________ 

Employee was Employed to:  _____________________

Reason For leaving:__________________________________________________________

Number of DOT Recordable Accidents: __________________________________________    

Preventable: _______________________________________________________________

Number of non-DOT Recordable Accidents/Incidents:_______________________________    

Preventable: _______________________________________________________________

Was applicant's Drivers License ever suspended or revoked?                                                    

Yes       No

Was applicant's general conduct satisfactory?                                                                

Yes       No

Was there a history of absenteeism or tardiness on this applicant?                                          

Yes       No

Did this applicant give adequate notice prior to leaving your employment?                                    

Yes       No

It is a violation of our policy to release information other than that information provided here.        

Yes       No

Federal law requires that DOT regulated employers respond in a timely manner to these requests. If a previous employer fails to respond to the request, it is the requirement of law that the potential or new employer submit documentation that a previous employer failed to respond to the CFR 49 Drug and Alcohol Request.

Employer representative completing form: __________________________________________

Signature: ________________________________________________________________

Date Completed: ___________

Telephone Number of Representative: ______________________

Title of Representative: _______________________________________________________

Attempt #1 Sent: ___________ Date: ____ / ____ / ______  Time____ : _____        

Attempt #2 Sent: __________  Date: ____ / ____ / ______   Time____ : _____

Request/Consent for previous employment 49 CFR Part 40 Drug and Alcohol #6

Applicants that desire to drive in intrastate/interstate commerce must provide the following information on ALL EMPLOYERS during the previous three years. Additionally, you must provide the same information for all employers you HAVE DRIVEN A COMMERCIAL MOTOR VEHICLE for for the seven years prior to the initial three years (total of ten years employment record for CDL drivers)

SECTION 1: To be completed by the applicant for submission to previous employer. All fields are required.

Requesting Company Name:

Applicant Name:

Applicant Address:

Applicant Telephone:

Applicant Email Address:

Social Security Number:

Previous Employer:

Previous Employer Manager:

Previous Employer Address:

Previous Employer Telephone:

Previous Employer FAX:  

Previous Employer Email:

Employed From:

Employed to (enter current date if still employed):

Do you intend to remain employed with this employer:

Final hourly rate of Pay:

Reason for Leaving:

Were you subject to the Federal Motor Carrier Safety Regulations (FMCSRs) While employed by this employer?

Was the previous job position designated as a safety sensitive function in any DOT regulated mode, subject to alcohol and controlled substances testing requirements as required by 49 CFR Part 49?

SECTION 2: To be completed by the applicant. As required by CFR 49 Part 391.23(c), we are forwarding this inquiry on the above named person who has made application to the above referenced company for employment as a commercial vehicle operator or mechanic. We respectfully request that you reply to this inquiry to the extent that your company policy allows, regarding this applicant. The applicant has signed the attached liability release for your records.

RELEASE of INFORMATION Form-49 CFR Part 40 Drug and Alcohol Testing:  I hereby authorize release of information from my Department of Transportation regulated drug and alcohol testing records by my  previous employer listed in Section 1, to the employer listed in the header section. This release is in accordance with DOT Regulation 49 CFR Part 40,  Section 40.25. I understand that information to be released in Section 3 by my previous employer is limited to the following DOT regulated testing items.

Items to be released: Alcohol Tests with a result of 0.04 or higher, Verified positive drug tests, Refusals to be tested, Other violations of DOT agency drug and alcohol testing regulations, Information obtained from previous employers of a drug and alcohol rule violations, and Documentation, if any, of completion of the return-to-duty process following a rule violation.

SECTION 3: To be completed by previous Employer and transmitted by mail, please fax or email to the new employer. Fax, Mail or Email with information listed at top of page.

Did the employee have alcohol tests with a drug result of 0.04 or higher?                            

Yes        No

Did the employee have verified positive drug results?                                                

Yes        No

Did the employee refuse to be tested?                                                                

Yes        No

Did the employee have other violations of DOT agency drug and alcohol testing rules?                

Yes        No

Did a previous employer report a drug or alcohol rule violation to you?                            

Yes        No

If you answered yes to any of the above items, did the employee complete the return-to-duty process?

Yes       No

NOTE:  If you answered yes to item 5, you MUST provide the previous employer's report. If you answered "yes" to item 6, you must also transmit the appropriate return-to-duty documentation

(e.g., SAP report(s), follow up testing record).

SECTION 4: To be completed by previous Employer

Employee was Employed From:   _________________ 

Employee was Employed to:  _____________________

Reason For leaving:__________________________________________________________

Number of DOT Recordable Accidents: __________________________________________    

Preventable: _______________________________________________________________

Number of non-DOT Recordable Accidents/Incidents:_______________________________    

Preventable: _______________________________________________________________

Was applicant's Drivers License ever suspended or revoked?                                                    

Yes       No

Was applicant's general conduct satisfactory?                                                                

Yes       No

Was there a history of absenteeism or tardiness on this applicant?                                            

Yes       No

Did this applicant give adequate notice prior to leaving your employment?                                    

Yes       No

It is a violation of our policy to release information other than that information provided here.    

Yes       No

Federal law requires that DOT regulated employers respond in a timely manner to these requests. If a previous employer fails to respond to the request, it is the requirement of law that the potential or new employer submit documentation that a previous employer failed to respond to the CFR 49 Drug and Alcohol Request.

Employer representative completing form: __________________________________________

Signature: ________________________________________________________________

Date Completed: ___________

Telephone Number of Representative: ______________________

Title of Representative: _______________________________________________________

Attempt #1 Sent: ___________ Date: ____ / ____ / ______  Time____ : _____        

Attempt #2 Sent: __________  Date: ____ / ____ / ______   Time____ : _____

Request/Consent for previous employment 49 CFR Part 40 Drug and Alcohol #7

Applicants that desire to drive in intrastate/interstate commerce must provide the following information on ALL EMPLOYERS during the previous three years. Additionally, you must provide the same information for all employers you HAVE DRIVEN A COMMERCIAL MOTOR VEHICLE for for the seven years prior to the initial three years (total of ten years employment record for CDL drivers)

SECTION 1: To be completed by the applicant for submission to previous employer. All fields are required.

Requesting Company Name:

Applicant Name:

Applicant Address:

Applicant Telephone:

Applicant Email Address:

Social Security Number:

Previous Employer:

Previous Employer Manager:

Previous Employer Address:

Previous Employer Telephone:

Previous Employer FAX:  

Previous Employer Email:

Employed From:

Employed to (enter current date if still employed):

Do you intend to remain employed with this employer:

Final hourly rate of Pay:

Reason for Leaving:

Were you subject to the Federal Motor Carrier Safety Regulations (FMCSRs) While employed by this employer?

Was the previous job position designated as a safety sensitive function in any DOT regulated mode, subject to alcohol and controlled substances testing requirements as required by 49 CFR Part 49?

SECTION 2: To be completed by the applicant. As required by CFR 49 Part 391.23(c), we are forwarding this inquiry on the above named person who has made application to the above referenced company for employment as a commercial vehicle operator or mechanic. We respectfully request that you reply to this inquiry to the extent that your company policy allows, regarding this applicant. The applicant has signed the attached liability release for your records.

RELEASE of INFORMATION Form-49 CFR Part 40 Drug and Alcohol Testing:  I hereby authorize release of information from my Department of Transportation regulated drug and alcohol testing records by my  previous employer listed in Section 1, to the employer listed in the header section. This release is in accordance with DOT Regulation 49 CFR Part 40,  Section 40.25. I understand that information to be released in Section 3 by my previous employer is limited to the following DOT regulated testing items.

Items to be released: Alcohol Tests with a result of 0.04 or higher, Verified positive drug tests, Refusals to be tested, Other violations of DOT agency drug and alcohol testing regulations, Information obtained from previous employers of a drug and alcohol rule violations, and Documentation, if any, of completion of the return-to-duty process following a rule violation.

SECTION 3: To be completed by previous Employer and transmitted by mail, please fax or email to the new employer. Fax, Mail or Email with information listed at top of page.

Did the employee have alcohol tests with a drug result of 0.04 or higher?                            

Yes        No

Did the employee have verified positive drug results?                                                

Yes        No

Did the employee refuse to be tested?                                                                

Yes        No

Did the employee have other violations of DOT agency drug and alcohol testing rules?                

Yes        No

Did a previous employer report a drug or alcohol rule violation to you?                            

Yes        No

If you answered yes to any of the above items, did the employee complete the return-to-duty process?

Yes       No

NOTE:  If you answered yes to item 5, you MUST provide the previous employer's report. If you answered "yes" to item 6, you must also transmit the appropriate return-to-duty documentation

(e.g., SAP report(s), follow up testing record).

SECTION 4: To be completed by previous Employer

Employee was Employed From:   _________________ 

Employee was Employed to:  _____________________

Reason For leaving:__________________________________________________________

Number of DOT Recordable Accidents: __________________________________________    

Preventable: _______________________________________________________________

Number of non-DOT Recordable Accidents/Incidents:_______________________________    

Preventable: _______________________________________________________________

Was applicant's Drivers License ever suspended or revoked?                                                    

Yes       No

Was applicant's general conduct satisfactory?                                                                

Yes       No

Was there a history of absenteeism or tardiness on this applicant?                                            

Yes       No

Did this applicant give adequate notice prior to leaving your employment?                                    

Yes       No

It is a violation of our policy to release information other than that information provided here.

Yes       No

Federal law requires that DOT regulated employers respond in a timely manner to these requests. If a previous employer fails to respond to the request, it is the requirement of law that the potential or new employer submit documentation that a previous employer failed to respond to the CFR 49 Drug and Alcohol Request.

Employer representative completing form: __________________________________________

Signature: ________________________________________________________________

Date Completed: ___________

Telephone Number of Representative: ______________________

Title of Representative: _______________________________________________________

Attempt #1 Sent: ___________ Date: ____ / ____ / ______  Time____ : _____        

Attempt #2 Sent: __________  Date: ____ / ____ / ______   Time____ : _____

Request/Consent for previous employment 49 CFR Part 40 Drug and Alcohol #8

Applicants that desire to drive in intrastate/interstate commerce must provide the following information on ALL EMPLOYERS during the previous three years. Additionally, you must provide the same information for all employers you HAVE DRIVEN A COMMERCIAL MOTOR VEHICLE for for the seven years prior to the initial three years (total of ten years employment record for CDL drivers)

SECTION 1: To be completed by the applicant for submission to previous employer. All fields are required.

Requesting Company Name:

Applicant Name:

Applicant Address:

Applicant Telephone:

Applicant Email Address:

Social Security Number:

Previous Employer:

Previous Employer Manager:

Previous Employer Address:

Previous Employer Telephone:

Previous Employer FAX:  

Previous Employer Email:

Employed From:

Employed to (enter current date if still employed):

Do you intend to remain employed with this employer:

Final hourly rate of Pay:

Reason for Leaving:

Were you subject to the Federal Motor Carrier Safety Regulations (FMCSRs) While employed by this employer?

Was the previous job position designated as a safety sensitive function in any DOT regulated mode, subject to alcohol and controlled substances testing requirements as required by 49 CFR Part 49?

SECTION 2: To be completed by the applicant. As required by CFR 49 Part 391.23(c), we are forwarding this inquiry on the above named person who has made application to the above referenced company for employment as a commercial vehicle operator or mechanic. We respectfully request that you reply to this inquiry to the extent that your company policy allows, regarding this applicant. The applicant has signed the attached liability release for your records.

RELEASE of INFORMATION Form-49 CFR Part 40 Drug and Alcohol Testing:  I hereby authorize release of information from my Department of Transportation regulated drug and alcohol testing records by my  previous employer listed in Section 1, to the employer listed in the header section. This release is in accordance with DOT Regulation 49 CFR Part 40,  Section 40.25. I understand that information to be released in Section 3 by my previous employer is limited to the following DOT regulated testing items.

Items to be released: Alcohol Tests with a result of 0.04 or higher, Verified positive drug tests, Refusals to be tested, Other violations of DOT agency drug and alcohol testing regulations, Information obtained from previous employers of a drug and alcohol rule violations, and Documentation, if any, of completion of the return-to-duty process following a rule violation.

SECTION 3: To be completed by previous Employer and transmitted by mail, please fax or email to the new employer. Fax, Mail or Email with information listed at top of page.

Did the employee have alcohol tests with a drug result of 0.04 or higher?                            

Yes        No

Did the employee have verified positive drug results?                                                

Yes        No

Did the employee refuse to be tested?                                                                

Yes        No

Did the employee have other violations of DOT agency drug and alcohol testing rules?                

Yes        No

Did a previous employer report a drug or alcohol rule violation to you?                              

Yes       No

If you answered yes to any of the above items, did the employee complete the return-to-duty process?

Yes       No

NOTE:  If you answered yes to item 5, you MUST provide the previous employer's report. If you answered "yes" to item 6, you must also transmit the appropriate return-to-duty documentation

(e.g., SAP report(s), follow up testing record).

SECTION 4: To be completed by previous Employer

Employee was Employed From:   _________________ 

Employee was Employed to:  _____________________

Reason For leaving:__________________________________________________________

Number of DOT Recordable Accidents: __________________________________________    

Preventable: _______________________________________________________________

Number of non-DOT Recordable Accidents/Incidents:_______________________________    

Preventable: _______________________________________________________________

Was applicant's Drivers License ever suspended or revoked?                                                    

Yes       No

Was applicant's general conduct satisfactory?                                                                

Yes       No

Was there a history of absenteeism or tardiness on this applicant?                                            

Yes       No

Did this applicant give adequate notice prior to leaving your employment?                                    

Yes       No

It is a violation of our policy to release information other than that information provided here.

Yes       No

Federal law requires that DOT regulated employers respond in a timely manner to these requests. If a previous employer fails to respond to the request, it is the requirement of law that the potential or new employer submit documentation that a previous employer failed to respond to the CFR 49 Drug and Alcohol Request.

Employer representative completing form: __________________________________________

Signature: ________________________________________________________________

Date Completed: ___________

Telephone Number of Representative: ______________________

Title of Representative: _______________________________________________________

Attempt #1 Sent: ___________ Date: ____ / ____ / ______  Time____ : _____        

Attempt #2 Sent: __________  Date: ____ / ____ / ______   Time____ : _____

 

 

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Document name: Supplemental CFR Request
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May 30, 2017 7:48 pm CDTSupplemental CFR Request Uploaded by Kevin Ertz - kevin@gowindstar.com IP 73.225.51.145
August 14, 2017 7:35 pm CDT Document owner admin@gowindstarsafety.com has handed over this document to kevin@gowindstar.com 2017-08-14 19:35:44 - 70.194.12.103