Request for dot information safety-sensitive former employees

YES 
□
NO 
□
If “YES”, please explain: ___________________________________________________________________________
5. Did the applicant pose either repeated and/or severe disciplinary problems ?
YES 
□
NO 
□
If “YES”, please explain: ___________________________________________________________________________ 
6. Why did applicant leave your employment ?
RESIGNED
 
□
,

DISCHARGED

 
□
, 
LAID OFF
 
□
7. Did this employee test positive or refuse to be tested on a non-DOT Drug/Alcohol test ?
YES 
□
NO 
□
If “YES”, please explain: ___________________________________________________________________________ 
WAIVER AND DIRECTION TO RELEASE INFORMATION 
I hereby authorize my former employers to release all safety and performance history information concerning my 
employment, including, safety information, non-DOT drug/alcohol testing records, job performance, ability, 
separation information, to 
FLC TRANSPORT LLC
(or their authorized agents) in connection with my application for 
employment. I hereby release you and your Company or Entity and waive any claim of liability of any type as a result 
of providing the above request information. 
NAME OF APPLICANT
____________________________________________________________________________________ 
SIGNATURE OF APPLICANT
 _____________________________________________ 
DATE
_____________________________ 
WITNESS SIGNATURE
____________________ 
WITNESS PRINTED NAME
__________________________________________ 
TO BE COMPLETED BY PROSPECTIVE EMPLOYER 
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