I understand that information I provide regarding current and/or previous employers may be used, and those employer(s) will be contacted, for the purpose of investigating my safety performance history as required by 49 CFR 391.23(d) and (e). 

I understand that I have the right to: 

• Review information provided by current/previous employers; 

• Have errors in the information corrected by previous employers and for those previous employers to re-send the corrected information to the prospective employer; and 

• Have a rebuttal statement attached to the alleged erroneous information if the previous employer(s) and I cannot agree on the accuracy of the information.

RECIPIENT EMPLOYER: The individual identified in SECTION 1 below has indicated that you employ(ed) or use(d) him/her within
the last 3 years in a position that involved the operation of a commercial motor vehicle and/or that was subject to U.S. Department
of Transportation (DOT)-regulated drug and alcohol testing.
In accordance with 49 CFR §§40.25 and 391.23, we are hereby requesting that you supply us with the Safety Performance History
of this individual. Under DOT rule §391.23(g), you must respond to this inquiry within 30 days of receipt.
Please complete SECTIONS 2 through 4 (as applicable) and return to the prospective employer shown in SECTION 1.
APPLICANT: Complete SECTION 1 and submit to prospective employer.
PROSPECTIVE EMPLOYER: Complete SECTION 5a and send form to current/previous employer. Upon receipt of completed
form, complete SECTION 5b and retain.

EMPLOYMENT VERIFICATION

ACCIDENT HISTORY

Complete the following for any accidents included on your accident register (§390.15(b)) that involved the applicant in the 3 years prior to the application date shown on SIDE 1  

For each record, provide the following information

1. Date
2. Location
3. No. of Injuries
4. No. of Fatalities
5. Hazmat Spill

DRUG AND ALCOHOL HISTORY

In answering these questions, include any required DOT drug or alcohol testing information you obtained from other employers in the 3 years prior to the application date shown on SIDE 1. 

Within the past 3 years from the application date shown on SIDE 1:

Complete below when information is obtained.

I acknowledge receipt of the separate document entitled DISCLOSURE REGARDING BACKGROUND INVESTIGATION,
DISCLOSURE REGARDING INVESTIGATIVE BACKGROUND INVESTIGATION and A SUMMARY OF YOUR RIGHTS UNDER
THE FAIR CREDIT REPORTING ACT and additional state/city-specific notices and Summary of Rights and certify that I have read and understood those documents.

I hereby authorize the evaluation of my driver file by BBR Transport LLC & Associates, Inc. for
compliance with state and federal laws and the acquisition of “consumer reports” (i.e., driving records, criminal history, social security verification, and/or education history) and/or “investigative consumer reports” (i.e., employment and/or education verification) by the Employer (as listed below) at any time after receipt of this authorization and throughout my employment, if applicable.

In addition, I hereby authorize any law enforcement agency, administrator, state or federal agency, institution, school or university (public or private), information service bureau, current and past employer, or insurance company to furnish any and all background information requested by BBR Transport LLC & Associates, Inc., PO Box 368, Neenah, WI 54957-0368,
(877)-564-2333, www.bbrtransportllc.com, and/or Employer itself. I agree that a facsimile (“fax”), electronic or photographic copy of this Authorization shall be as valid as the original.

This document should NOT be construed as legal advice, guidance or counsel. Employers should consult their own attorney about their compliance responsibilities under the FCRA and applicable state law. BBR Transport LLC & Associates, Inc., expressly disclaims any warranties or responsibility or damages associated with or arising out of information provided. Employers seeking credit reports must provide additional notices pursuant to state law.

Certification of Violations/Annual Review of Driving Record

MOTOR CARRIER INSTRUCTIONS: Each motor carrier shall at least once every 12 months, require each driver it employs to prepare and furnish it with a list of all violations of motor vehicle traffic laws and ordinances (other than violations involving only parking) of which the driver has been convicted, or on account of which he/she has forfeited bond or collateral during the preceding 12 months (Section 391.27). Drivers who have provided information required by Section 383.31 need not repeat that information on this form. 

DRIVER REQUIREMENTS: Each driver shall furnish the list as required by the motor carrier above. If the driver has not been convicted of, or forfeited bond or collateral on account of any violation which must be listed, he/she shall so certify (Section 391.27).  

1. DATE
2. OFFENSE
3. LOCATION 
4. TYPE OF VEHICLE OPERATED  

MEDICAL EXAMINER NATIONAL REGISTRY VERIFICATION 

MOTOR CARRIER INSTRUCTIONS: For each Medical Examiner’s Certificate issued to a commercial motor vehicle driver, the motor carrier must verify that the medical examiner who signed the driver’s medical card is listed on the National Registry. This requirement 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 a 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 qualification file, before allowing the driver to operate a CMV. 

§391.51 General requirements for driver qualification files. (b) (9) (i) For drivers not required to have a CDL, a note relating to verification of medical examiner listing on the National Registry of Certified Medical Examiners required by §391.23(m)(1). (b)(9)(ii) Until June 22, 2018, for drivers required to have a CDL, a note relating to verification of medical examiner listing on the National Registry of Certified Medical Examiners required by §391.23 (m) (2). 

RETENTION: This form is to be kept in the driver’s qualification file for 3 years. 

MOTOR CARRIER VERIFICATION: The following medical examiner has been verified as being listed on the National Registry of Certified Medical Examiners (NRCME) as of the date of issuance of the medical examiner’s certificate for the named driver.