Request for dot information safety-sensitive former employees

NAME OF APPLICANT
____________________________________________________________________________________ 
SIGNATURE OF APPLICANT
 _____________________________________________ 
DATE
_____________________________ 
WITNESS SIGNATURE
____________________ 
WITNESS PRINTED NAME
__________________________________________ 
FLC TRANSPORT
LLC
1715 INDIAN WOOD CIR
STE 281 MAUMEE
OH 43537
James Marckly Edmond (Jan 31, 2022 12:17 EST)
James Marckly Edmond
332-69-6761
James Marckly Edmond
Jan 31, 2022
Huffmaste
2485881600
1055 W Maple Rd, Clawson, MI 48017

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CONFIDENTIAL REQUEST FOR DOT INFORMATION (PAGE2) 
SAFETY-SENSITIVE FORMER EMPLOYEES (FMCSA06) SAFETY AND PERFORMANCE HISTORY 
FORMER EMPLOYER NAME ________________________________________________________________________________ 
1. What type(s) of work did he/she do ?
2. If employed as a driver, please check type of
equipment driven
□
Driver (type of vechicle)____________________
□
Shop
□
Office
□
Dock
□
Other __________________________
□
Tractor-Trailer
□
Stright Truck
□
Double-Triple
□
Bus
□
Other __________________________
3. Number of recordable accidents:
Number of accidents in which was applicant ticketed: ______
Number of accidents in which was applicant a fault: ______
Date of each accident: ____________________________________________________________________________
_______________________________________________________________________________________________
4. To your knowledge, was this person’s CDL / operator’s license suspended while in your employ ?