The Federal Motor Carrier Safety Regulations require all previous employers of this applicant to respond to this request for information within 30 days. Failure to comply with this request is in violation, for which you may be prosecuted. Questions concerning the requirements of this regulation should be directed to the MD Division Office of the Federal Motor Carrier Safety Administration during business hours.
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I, , hereby authorize to release all records of employment, including assessments of my job performance, ability and fitness, including the dates of any and all alcohol or drug tests, with confirmed results, and/or my refusal to submit to any alcohol and drug tests and any rehabilitation completion under direction of a substance abuse professional (SAP) and/or medical review officer (MRO) to each and every company (or their authorized agents) making such request in connection with my application for employment with said company. I, hereby, release the above named company, and its employees, officers, directors and agents from any and all liability of any type as a result of providing the following information to the below mentioned person and/or company.
REQUEST FROM
Company : MBG Refuse Service Inc
Address: 7457 Shipley Ave, Harmans Maryland 21077
Telephone#: 410-766-3621
Contact Person & Title: Brigitte Smith/ Human Resources Dept.
INQUIRY INTO EMPLOYMENT HISTORY - PAST THREE YEARS
Did applicant work from to as a
YES / NO; If NO, explain:
If employed as a driver, please choose the position that best describes applicant's employment:
Company Driver Owner/ Operator Other
Type of truck(s) and/or truck / tractor(s) operated:
Commodities transported: Area of operations
Accidents? YES / NO If YES, please give date(s) and brief description of each accident:
Why did this employee leave your company?
Would you re-employ this person? YES / NO If NO, please explain: _________________________
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Additional comments: ___________________________________________________________________
Thanks for your submission!
