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Subject:  Driver’s Written Authorization to Release Information

If you were NOT operating a commercial motor vehicle anytime in the preceding 10 years.

You are required by 49 CFR 391.21 b, 10 to submit information for every employer worked for the last 3 years.

Submit 1 form for each Previous Employer.

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If you were operating a commercial motor vehicle anytime in the preceding 10 years.

You are required by 49 CFR 391.21 b, 11 to submit information for every employer you worked for the last 10 years for whom you operated a commercial motor vehicle.

Submit 1 form for each Previous Employer.

Driver’s Written Authorization to Release Information

Part 39 1.23(f)(l) requires that prospective employers provide an applicant's previous employer(s) with the driver's written consent when requesting drug and alcohol testing information as part of the Safety Performance History inquiry required by the Federal Motor Carrier Safety Administration (FMCSA). Have the driver sign one release per previous employer. Send separate release forms to each of the driver's previous employers to insure that the driver's prior employment information is kept confidential.


A photocopy of this release shall be as valid as the original. This authorization shall be valid for one year from the date of signing hereof.

I hereby Authorize

to release information that verifies my previous employment and Safety Performance History as required by 49 CFR Part 391.23 within 30 days of receiving this authorization.


By signing this release I acknowledge that the information released will be used by the Prospective Employer named below when making their hiring decision and will be kept confidential.

This certifies that this application was completed by me, and that all entries on it and information in it are true and complete to the best of my knowledge.

Date
Month
Day
Year

Prospective Employer: Anthony Bill Trucking

Employer Representative: _____________________________________________________

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