Safety Performance History Records Request


Safety Performance History Records Request

Section 1: To be completed by prospective employee

I (Print Name)
 
First, M.I., Last
Social Security Number
Date of Birth

Hereby authorize:

Previous Employer:
 
Telephone:
 
Street:
 
Fax No.:
 
City, State, Zip:
 

To release and forward the information requested by section 3 of this document concerning my Alcohol and

Controlled Substance Testing records within the previous 3 years from
 
to
 
 
(date of employment application)

Attn:
 
Phone:
 

Prospective Employer: INTER FREIGHT INC
Street: 2319 Cline Avenue
City, State, Zip: Gary, IN 46406
Fax : 888-600-8510

In compliance with §40.25(g) and 391.23(h), release of this information must be made in a written form that ensures confidentiality , such as fax, letter or e-mail.

Leave this empty:

Signature Certificate
Document name: Safety Performance History Records Request
Unique Document ID: dc4331107539c0ee5f4b564f33e0890bd9b59e6b
Timestamp Audit
February 13, 2018 5:08 pm CSTSafety Performance History Records Request Uploaded by Jovica Kolar - jkolar@interfreight.us IP 73.211.26.185
February 15, 2018 12:24 pm CSTInter Freight Safety - safety@interfreight.us added by Jovica Kolar - jkolar@interfreight.us as a CC'd Recipient Ip: 73.211.26.185
February 23, 2018 11:10 am CSTInter Freight Safety - safety@interfreight.us added by Jovica Kolar - jkolar@interfreight.us as a CC'd Recipient Ip: 73.211.26.185
February 23, 2018 11:10 am CSTInter Freight Admin - jkolar@interfreight.us added by Jovica Kolar - jkolar@interfreight.us as a CC'd Recipient Ip: 73.211.26.185