Request for dot information safety-sensitive former employees

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CONFIDENTIAL REQUEST FOR DOT INFORMATION SAFETY-SENSITIVE FORMER EMPLOYEES (FMCSA06) (PAGE1) 
Requested by: 
FLC TRANSPORT LLC
 
TO: 
FROM:
 
FLC TRANSPORT LLC
 
1715 INDIAN WOOD CIR STE 
281 MAUMEE, OH 43537
E-mail:
safety@
flctransport
.
us
 
________________________________________________________________________________________
_______ 
NAME (of former employer)
Contact 
_______________________________________________________________________________________________ 
Address
City / State / Zip 
NAME OF APPLICANT
______________________________________________________ 
SSN#
_________________________
________________________ has made application to 
FLC TRANSPORT LLC
for a safety-sensitive function under DOT 
regulations and pursuant to 49 CFR Part 40.25, 40.321(b) and 49 CFR Part 382.413, 391.23(a)(1) we are hereby requesting 
that your entity provide the information requested below, and on page 2.
 
PLEASE COMPLETTE FOLLOWING (FOR THE PAST 3 YEARS) 
1.
 
What were the dates of this applicant’s employment ? From _______________________ To _______________________
2.
Was he employed in a DOT safety-sensitive function ?
YES 
□
NO 
□
If yes, what position ? _________________________________________________________________________________ 
3.
Did the employee have alcohol test with a result of 0.04 or higher ?
YES 
□

 NO 
□
4.
Did the employee have verified positive drug test ?