Driver Qualification and Release of Information I hereby authorize you to release the following information to NELSON FREIGHT SERVICE, INC. as required by 49 CFR Part 40, Part 382.405 (f) (h), Part 382.413 (b) (e) (f), and Part 391.23 of the Federal Motor Carrier Safety Regulations. You are hereby released from any and all liability which may result from furnishing such information. A photocopy of this release shall be as valid as the original. This authorization shall be valid for one year from the date of signing hereof. Application Date Applicant Signature Name of Applicant SS Number Employer Name Address City State Zip Employed From Employed To What Did the Applicant Drive For You BusStraight TruckTractor/SemiTrailer ComboOther If Other: Was applicant a safe and efficient driver? NoYes Was applicant’s general conduct satisfactory? NoYes Reason For Leaving Your Employ DischargedLaid-OffMilitary Call-UPResignation Disposition, Tact, Ability to Get Along with Others ExcellentGoodFairPoor Initiative, Resourcefulness ExcellentGoodFairPoor Safety Habits ExcellentGoodFairPoor Driving Skills ExcellentGoodFairPoor Attitude ExcellentGoodFairPoor Loyalty ExcellentGoodFairPoor Any Known Physical Disabilities or Deformities? NoYes If Yes, Please Explain Any other remarks about the performance or the physical health of the applicant can be made here: Pursuant to 49 CFR Part 40, Part 382, we request that any and all information related to alcohol and controlled substances testing of Commercial Motor Vehicle licensed drivers be released to us, covering a period of time of two years prior to the date of this inquiry. Please be aware that the regulations clearly state that this information must be answered and released to us, regardless of any company policy which may be in effect at this time. Was applicant subject to: Breath and Alcohol TestingDrug Testing If yes, please answer the following: Has this person tested positive for a controlled substance in the last two (2) years? NoYes If yes, please indicate the type of test and test date: Test Date: Has this person had an alcohol test with a breath alcohol concentration of 0.04 or greater in the last two years? NoYes If yes, please indicate the type of test and test date: Test Date Has this person refused a required test for drugs or alcohol in the last two (2) years? NoYes If yes, please indicate the scheduled test date and reason of refusal: Test Date Has this person violated any other Drug & Alcohol Regulation? NoYes If yes, please indicate the violation: If the answer was yes to any of the above questions, please give the name, address, and phone numbers of attending SAPs (Substance Abuse Professionals). Signature Title Date