Safety Performance History Records Request
(TO BE COMPLETED BY PROSPECTIVE EMPLOYEE)
I,
(First, M.I., Last)
Social Security Number
Date of Birth
 
 
HEREBY AUTHORIZE Automated Transportation, LLC to make make such investigations and inquiries of my personal, employment, financial, or medical history and other related matters as may be necessary in arriving at an employment decision. (Generally, inquiries regarding medical history will be made only if and after a conditional offer of employment has been extended.) I hereby release employers, schools, health care providers, and other persons from all liability in responding to inquiries and releasing information in connection with my application.

I hereby authorize all previous employers to release and forward the information requested concerning my personal, employment, financial, or medical history. I also authorize the release of records of my controlled substance and alcohol testing in accordance to Federal Motor Carrier Safety Regulation.
TO:  
Prospective Employer:  Automated Transportation, LLC
Attention:   HR  
Telephone: 812-375-7785
Address: 16920 N State Road 545
St. Meinrad, IN. 47577

In compliance with §40.25(g) and §391.23 (h), release of this information
must be made in a written form that ensures confidentiality.

Prospective employer's confidential fax number: 812-357-7784

Prospective employer's confidential email address: valeriek@automatedtransportation.us

________________________________________
____________
Applicant's Signature
Date
This information is being requested in compliance with §40.25 and §391.23


Please print, sign, and fax this form to (812) 357-7784, Attn: Valerie