MZK Transport – Driver Employment Verification

Section 1 — Driver Information (Pre-filled by MZK Transport)

Driver Full Name *

Last 4 of SSN

Date of Birth

Employment Dates at Your Company — From

Employment Dates at Your Company — To

I hereby authorize the release of information requested on this form. I understand that previous employers may give information about my work history.

Driver Signature (type full name)

By typing your name you agree this serves as your electronic signature.

Section 2 — Prospective Employer (MZK Transport Inc.)

Company

MZK Transport Inc.

Contact

Ana B.

Title

Safety Manager

Phone

(224) 935-4430

Email

ana@mzktrans.com

Section 3 — Employment Verification Questionnaire (Complete by Previous Employer)

Employment Details

Dates Employed — From

Dates Employed — To

Position Held

Type of Driving

OTR Regional Local Not Applicable

Type of Operation

Interstate Intrastate Both

Equipment Operated

Tractor-Trailer (18-wheeler) Straight Truck Other:

Trailer Types

Commodities Hauled

Accident / Incident Record

Date	Type	Fatalities	Injuries	Description

No accidents on record

Additional Questions

1. Did the driver give proper notice before leaving?

Yes No N/A

2. Was the driver terminated?

Yes No N/A

3. Is the driver eligible for rehire?

Yes No N/A

Reason for Leaving / Not Eligible for Rehire

Section 4 — Drug & Alcohol Testing (49 CFR Part 40 & 382)

1. Did the driver take a pre-employment drug test?

Yes No N/A

2. Did the driver test positive for any controlled substance?

Yes No N/A

3. Did the driver refuse to submit to a required drug or alcohol test?

Yes No N/A

4. Did the driver violate any DOT drug and alcohol regulations?

Yes No N/A

5. Was the driver required to complete a SAP (Substance Abuse Professional) program?

Yes No N/A

6. If SAP program was required, did the driver complete it and return to safety-sensitive duties?

Yes No N/A

Section 5 — Person Completing This Form (Previous Employer)

Full Name *

Title / Position

Company Name *

Phone

Date

Electronic Signature (type full name) *

By typing your name you certify that the information provided is accurate to the best of your knowledge.