• SAFETY PERFORMANCE HISTORY

  • DOB
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    2 digit month, 2 digit day, 4 digit year
  • Date
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    2 digit month, 2 digit day, 4 digit year

  • I hereby authorize previous employers to release and forward the information requested by concerning my Alcohol and Controlled Substances testing records within the previous three (3) years from date of application. To: TRANSAFE OBO

    BRAVO MOTOR CARRIERS INC

    9009 North Loop East Ste 200

    Houston, TX 77029

    In compliance with 40.25 (g) and 391.23 (h), release of this information must be made in Written form that ensures confidentiality such as fax, email, or letter.

  • Format: (000) 000-0000.

  • To BE COMPLETED BY: PREVIOUS EMPLOYER

  • Section I. Employment Verification

  • Section II. Experience

  • Did he/she drive a motor vehicle for you?
  • If yes, what type?

  • Section III. Separation Reason

  • Reason for leaving your employment:

  • Section IV. Accident Register (390.15(b))

  • Rows

  • Section V. Certification

  • Date
     / /
    2 digit month, 2 digit day, 4 digit year

  • SAFETY PERFORMANCE HISTORY

  • To BE COMPLETED BY: PREVIOUS EMPLOYER

     

  • Section 1. Drug and Alcohol History

  • DATES OF EMPLOYMENT
     / /
    2 digit month, 2 digit day, 4 digit year
  • 1. Has this person had an alcohol test with a result of 0.04 or higher alcohol concentration?
  • 2. Has this person tested positive, adulterated, or substituted a test specimen for controlled substances?
  • 3. Has this person refused to submit to post-accident, random, reasonable suspicion, or follow-up alcohol or controlled substance test?
  • 4. Has this person committed other violations of Subpart B of Part 382, or Part 40?
  • 5. If this person has violated a DOT drug and alcohol regulation, did this person complete a SAP-prescribed rehabilitation program in your employ, including return-to-duty and follow up tests? If yes, please send documentation back with this form
  • 6. For a driver who successfully completed a SAP's rehabilitation referral and remained in your employment, has driver subsequently had an alcohol test result of 0.04 or greater, a verified positive drug test, or refusal to be tested?

  • Section II. If the answer to QUESTION 5 or 6 is "YES", please SAP Professional Information

  • Format: (000) 000-0000.

  • Section III. Affirmation: This form was filled out by:

  • Date
     / /
    2 digit month, 2 digit day, 4 digit year
  • This form was
  • DATE
     / /
    2 digit month, 2 digit day, 4 digit year
  •  
  • Should be Empty: