Application Form 2 – Unity Freight

Safety Performance History Data

Previous employers must complete the following three (3) areas and return within 30 days of receipt in accordance with 49 CFR §391.23(g).

1. Employment Verification

Was or is the above-mentioned applicant employed* with your motor carrier?

(*Employed may be taken to mean utilized under your USDOT number, even though he / she was not an employee under other agency definitions such as IRS or DOL.)

Job Title

Date employed From

Date employed To

Did he / she operate a commercial motor vehicle for you?

If yes, Indicate type(s)

Straight truck
Tractor-Semitrailer
Bus
Cargo Tank
Doubles / Triples

Other (list)

Completed by

Company

Address

Address Line 1

City

State

Zip Code

Telephone

Signature

Date

Employee's Name

First

Last

Date

2. Accident History

Please list any accidents included on your motor carrier's accident register (§390.15(b)) that involved the applicant. They must reflect all accidents three (3) years prior to the date of application indicated in the AUTHORIZATION / SPECIFIC WRITTEN CONSENT portion of this form on Page 1.

1. Date

Location

No. of Injuries

No. of Fatalities

Hazmat Spill

2. Date

Location

No. of Injuries

No. of Fatalities

Hazmat Spill

3. Date

Location

No. of Injuries

No. of Fatalities

Hazmat Spill

Please provide information concerning other accidents not appearing on your accident register involving a commercial motor vehicle that were reported to government agencies or insurers or retained under company policies:

3. Dot Drug & Alcohol Testing History

If the applicant was not subject to DOT testing requirements under 49 CFR Part 40 while employed with you.

Click Here and return

In the three (3) years prior to the date of the employee's signature (see AUTHORIZATION / SPECIFIC WRITTEN CONSENT), for DOT regulated testing:

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

2. Did the employee have verified positive drug tests?

3. Did the employee refuse to be tested?

4. Did the employee have other violations of DOT agency drug and alcohol testing regulations?

5. Did a previous employer report a drug and alcohol rule violation to you?

6. If your answered "yes" to any of the above items, did the employee complete the return-to-duty process?

NOTE: if you answered "yes" to item 5, you must provide the previous employer's report. If your answered "yes" to item 6, you must also transmit the appropriate return-to-duty documentation (e.g., SAP report(s), follow-up testing record).

Prospective Employer Documentation

Date sent to former DOT regulated employer:

Checkboxes

Method
Faxed
Emailed
Other

Sent by whom?

Title

Subsequent attempts as a good faith effort: (explain)

Was the information returned by the former employer?

If yes, date received

Checkboxes (copy)

Method
Faxed
Emailed
Other

Medical Examiner's National Registry Verification

MOTOR CARRIER INSTRUCTIONS: The requirement to include verification of the medical examiner's National Registry listing in the driver's qualification files was published in the Federal Register April 20, 2012. Beginning May 21, 2014, motor carriers must certify that the medical examiner who signed the driver's medical card is listed on the National Registry. This requirements is prescribed in §391.23 and §391.51.

§391.23 investigation and inquiries. (m)(1) The motor carrier must obtain an original or copy of the medical examiner's certificate issued in accordance with §391.43, and any medical variance on which the certification is based, and, beginning on or after May 21, 2014, verify the driver was certified by an medical examiner listed on the National Registry of Certified Medical Examiners as of the date of issuance of the medical examiner's certificate, and place the records in the driver qualifications file, before allowing the driver to operate a CMV. (§391.23(m)(L))

§391.51 General requirements for driver qualification files. (b)(9)A note relating to verification of medical examiner listing on the National Registry of Certified Medical Examiners required by §391.23(m). (§391.51(b)(9))

Motor Carrier Verification: The following medical examiner has been verified as being listed on the National Registry of Certified Medical Examiners as of the date of issuance of the medical examiner's certificate for the named driver

Driver's Name

Identification Number

Medical Examiner

National Registry Number

Motor Carrier

Location

Verified By

(Motor Carrier Representative Signature)

Date

Employment Safety History Request Form

Safety Performance History Data

1. Employment Verification

2. Accident History

3. Dot Drug & Alcohol Testing History

Prospective Employer Documentation

Medical Examiner's National Registry Verification

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