The information requested on this form is the information that is required by federal law. The information provided will be verified by the employer as required under various parts of 49 CFR including Part 382 and Part 391. The applicant understands that information regarding current and/or previous employers may be used and those employers may be contacted for the purpose of investigating the applicant’s safety performance history. Furthermore, the applicant understands that they have the right to review information provided by previous employers, have errors in the information corrected by previous employers and for those previous employers to resend the corrected information to the prospective employer, and have a rebuttal statement attached to the alleged erroneous information, if the previous employers and the applicant cannot agree on the accuracy of the information.
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1090 Manchester Ave.
Wabash, Indiana 46992