Employment Verification


A2CLogisticsCO
Phone :(833)562-3222
Fax : (312)796-9314

5240 W 47TH ST STE 7 ,Chicago IL 60638
PAST EMPLOYMENT SAFETY HISTORY REQUEST FROM:

A2C LOGISTICS CO.

Your promptness in this matter is appreciated, thank you.

 

 

 

The person named herein has applied to A2C LOGISTICS CO for employment in a safety-sensitive position.
I, id-df-ai-first-name id-df-ai-middle-name df-ai-last-name ,
the listed applicant below, hereby authorizes the following carrier, A2CLOGISTICS CO, to release all records of employment, including assessments of my job performance, ability, fitness and drug testing results to A2CLOGISTICS CO. I hereby release this company, and its employees, officers, directors, and agents from any, and all liability of any type as a result of providing the following information to the above-mentioned company. The applicant’s signature on this form releases all liability of you and your company. Information is being requested in accordance with 49 CFR Parts 40, 382 and 391.

Company                                                           Phone                                                                 Fax
________________________________                          _____________________________                              ______________________

Name of Applicant:  Social Security Number: ___________________

Dates of Employment: From___/___/___ To ___/___/___ Full Time: ___ Part-Time: ___

Position(s) Held: _____________________ Local: _____ Regional: ______ Over-The-Road: ______

Did this Operator operate commercial motor vehicles greater than 26,000 lbs GVWR? ___yes ___no

Type of Equipment Operated:Dry Van Flatbed Reefer Other (please list):

Reason for Leaving: ___Voluntary ___Lay-Off ___Terminated ___Retired
If Terminated, why?

Eligible for Rehire? ___Yes ___No ___Upon Review ___No, Company Policy

Motor Vehicle Accident/Equipment Damage/Incident Inquiry, If no accidents please check box none

Accident Date City, State Did the Accident Involve? Brief Description
___/___/___ Tow Injury Fatality HM Release
___/___/___ Tow Injury Fatality HM Release
___/___/___ Tow Injury Fatality HM Release
___/___/___ Tow Injury Fatality HM Release

Alcohol & Controlled Substance Testing Inquiry

Has this Operator ever had a breath alcohol test within the past 3 years a result of 0.04 or higher alcohol concentration?
___yes ___no

   Has this Operator ever had a positive drug test in the past 3 years?
   Has this Operator refused a controlled substance test and/or alcohol test within the past 3 years?
   Has this Operator violated any other DOT drug/alcohol regulation?
   If yes, please explain the violation:
___yes ___no
___yes ___no

___yes ___no

Have you ever received information from a previous employer that this Operator violated any DOT drug and alcohol regulations? __yes no

*If the answer to any of the above questions is “Yes”, please provide details below:

Reason for test(s): Result of test(s):

If the applicant tested positive, to your knowledge, have they satisfactorily completed all return to duty and follow-up testing requirements in
accordance 49 CFR 382.503? ___yes ___ No

Any other remarks:
Verification Completed By: ____________________________________________ Title:
Phone Number: _____________________________________ Verification Date: _____________________
First Request Date: ___/___/___ Second Request Date: ___/___/___ Third Request Date: ___/___/___
Fax___ Mail ___ Phone ___ Fax ___ Mail ___ Phone ____ Fax ___ Mail___ Phone ____

Leave this empty:

Signature arrow sign here

Signed by Catalin Chinces
Signed On: April 25, 2023


Signature Certificate
Document name: Employment Verification
lock iconUnique Document ID: 7e9afcc9ba0dcc04fe16a5b3495d1fd37b13fc3b
Timestamp Audit
March 11, 2023 5:33 am CSTEmployment Verification Uploaded by Catalin Chinces - office@truckinga2c.com IP 86.124.252.64
April 25, 2023 10:37 am CSTA2c - office@truckinga2c.com added by Catalin Chinces - office@truckinga2c.com as a CC'd Recipient Ip: 86.124.252.64
April 25, 2023 12:05 pm CSTA2c - office@truckinga2c.com added by Catalin Chinces - office@truckinga2c.com as a CC'd Recipient Ip: 86.124.252.64
April 25, 2023 12:07 pm CSTA2c - office@truckinga2c.com added by Catalin Chinces - office@truckinga2c.com as a CC'd Recipient Ip: 86.124.252.64
April 25, 2023 12:08 pm CSTA2c - office@truckinga2c.com added by Catalin Chinces - office@truckinga2c.com as a CC'd Recipient Ip: 86.124.252.64