MGR Freight System Hiring

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:
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
(date of employment application)


Prospective Employer: MGR FREIGHT SYSTEM INC
Street: P.O. BOX 328
City, State, Zip: Lyons, IL, 60534
Fax : (708)496-6500

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:

MGR Freight System Hiring
Signature Certificate
Document name: Safety Performance History Records Request
Unique Document ID: 525a936c397b7e14f4d174d59adb734ee30a41b4
Timestamp Audit
2016-08-13 08:18:25 CDTSafety Performance History Records Request Uploaded by Radomir Dobrasinovic - IP