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Employment History/Self-Employment Form

Phone# 208-516-6669, Fax# 800-520-9645, Email: safety@roamertransport.com

To Former Employer: The Federal Motor Carriers Safety Regulations Parts 391.23 & 382.413, require that a motor carries obtain previous employment information. Therefore, you are hereby authorized to give Roamer Transport Inc. all information regarding my duties, character, positive drug or alcohol results to submit to a required testing while in your employment.

Applicants Name: SSN: xxx-xx-

By signing this document below, the applicant agrees to authorize the aforementioned Previous Employer to give Roamer Transport Inc. all information regarding duties, character, and positive drug or alcohol results.

The above-named applicant has applied to Roamer Transport Inc. for a position as a Truck driver and states that He/She was employed by you as a - Driver From: ____________________ To: ____________________
Corrected

Are dates for employment correct as stated? Dates From: ____________________ To: ____________________

Did applicant drive an 18-wheeler? YES / NO Trailer type: _______________________________________________

Were trips DOT regulated? YES / NO

Was applicants conduct satisfactory? YES / NO Did you consider this person a safe driver? YES / NO

How many accidents in the last 3 years: ___________ Number Preventable: __________

Why did applicant leave your employment? ______________________________________________________________________________________________

Would you re-employ? YES / NO

Did applicant ever test positive for a controlled substance in the last 3 years? YES / NO

Has the applicant ever refused a test for drug or alcohol in the last 3 years? YES / NO

Has the applicant had an alcohol test with a Breath Alcohol concentration 0.04 or greater in the last 3 years? YES /NO

We appreciate your help in completing this information. Please return to safety@roamertransport.com or fax to (800) 520-9645 prefer email.

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September 15, 2020 2:49 pm MDT

Employment History/Self-Employment Form Uploaded by Roamer Transport - recruiting@roamertransport.com IP 173.47.82.139