DSTRILOGIX manages 5 data types including driver carrier assignments. Helps you organize, track, and share your work in 1 place for teams and solo users.

Safety Performance History Authorization and Request

This form authorizes prospective motor carriers to request and receive employment history, accident records, and drug/alcohol testing results from previous employers to comply with 49 CFR 391.23.

Full Name*

Phone Number*

Email Address*

Driver / Applicant Authorization

Driver Full Name*

Date of Birth*

SSN or Employee Identifier - Restricted*

Previous Employer Name*

Address*

Phone / Email*

Employment Dates*

Position*

Reason for Leaving*

Driver Printed Name*

Driver Signature*

By typing your name, you are electronically signing this document.

Date*

Prospective Employer Request

Prospective Motor Carrier*

USDOT Number*

Contact*

Request Date*

Method*

Response Due / Follow-Up Date*

Employment Verification

I agree

FMCSA-Defined Accidents

I agree

Drug / Alcohol Prohibition History

I agree

Return-to-Duty Status if applicable

I agree

Previous Employer Response

Employment Confirmed From*

To*

Position*

FMCSA-defined accidents during employment?*

Yes - details below

Unable to Verify

Accident Date

Accident Location

Accident Description

Fatalities / Injuries / Tow

Drug/alcohol prohibition or refusal information reportable?*

Yes - restricted detail attached

Unable to Verify

Responder Name / Title*

Phone / Email*

Response Date*

Responder Printed Name*

Signature*

By typing your name, you are electronically signing this document.

Date*

Good-Faith Contact Log

Attempt Date

Method

Contacted

Result / Notes