Safety Performance History Records Request
Request and authorize the release of safety performance history records for employment purposes.
Your Name (Requester)
*
First Name
Last Name
Your Organization/Company Name
*
Your Email Address
*
example@example.com
Your Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Employee/Driver Full Name
*
First Name
Last Name
Employee/Driver Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Last 4 Digits of Employee/Driver's License Number
*
Previous Employer Name
*
Previous Employer Contact Email
example@example.com
Previous Employer Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Employment Dates with Previous Employer
*
Type of Records Requested
*
Accident History
Drug and Alcohol Test Results
Safety Violations
Other (please specify below)
If Other, please specify the type of records requested
Additional Comments or Special Instructions
Signature of Employee/Driver (for release authorization)
*
Submit Request
Submit Request
Should be Empty: