<p> PAST EMPLOY MENT VERIFIC ATION The undersigned has applied for a driving position with Thomas Enterprises of Greensboro, Inc. I hereby authorize you to release the information requested, including assessments of my past performance and information concerning the results of any controlled substance or alcohol testing, or any refusal to test, pursuant to Federal Motor Carrier Safety Regulations, Section 382.413 and 391.23, while in your service. You are released from any and all liability, which may result from the release of this information.</p><p>Date: Applicant’s Signature</p><p>NOTE TO APPLICANT: DO NOT WRITE BELOW THIS LINE</p><p>Applicant Name (print) SS# Employer Phone ( ) Fax ( ) Address City State Zip Contact Title 1. Dates of employment:</p><p>2. Voluntary 3. Forced Job Title: Termination Termination DYES D NO DYES D NO gl e OTR</p><p>OT</p><p>Lo dent</p><p>3. Reason for leaving?</p><p>4. Would you rehire? Yes No If no, why not? </p><p>5. Number of accidents? (Give as much detailed information as possible.) Total number of accidents? </p><p>Date Nature of DOT Reportable Preventable Non- Injuries Fatalities Cost Accident Preventable</p><p>1 6. Number of Workers Comp Claims ? Number of Injuries? </p><p>2 PAST DRUG AND ALCOHOL TEST RESULTS</p><p>The above named individual has advised us that he/she worked for your company or that he/she applied to your company to work during the previous THREE (3) years. The Federal Motor Carrier Safety Regulations (FMSCR382.413 (a)(b)(c)(e)(f) require us to obtain from your company, and require your company to provide us information concerning the above named applicant’s past drug and alcohol test results (including refusals to be tested).</p><p>1. Has this person tested positive for a controlled substance in the last THREE (3) years? Yes No</p><p>2. Has this person had an alcohol test with a Breath Alcohol Concentration of 0.04 or greater in the last THREE (3) years? Yes No</p><p>3. Has this person refused a required test for drugs in the last THREE (3) years?. Yes No</p><p>4. Has this person violated other DOT drug/alcohol regulations? Yes No</p><p>5. Have you received information from a previous employer that this person violated DOT drug and alcohol regulations? Yes No</p><p>ADDITIONAL COMMENTS This information is held in strict confidence.</p><p>Signature of person releasing information / title Date</p>