Reset Form

DRIVER APPLICATION
Company Name: Allen Distribution Location: Region/District/Branch: Transportation
Company Address: 1532 Commerce Avenue, Carlisle PA 17015
Street City State Zip

TO BE READ AND SIGNED BY APPLICANT

I understand that information I provide regarding current and/or previous employers may be used, and those employer(s) will be contacted, for the purpose
of investigating my safety performance history as required by 49 CFR 391.23(d) and (e). I understand that I have the right to:
• Review information provided by current/previous employers;
• Have errors in the information corrected by previous employers and for those previous employers to re-send the corrected information to the
prospective employer; and
• Have a rebuttal statement attached to the alleged erroneous information if the previous employer(s) and I cannot agree on the accuracy of the
information.
Signature: Date:
Name:
Last First Middle

Social Security Number Phone Number Date of Birth Hire Date

Address:
Street City State Zip Number of Years

Past 3 Year
Residency: Street City State Zip Number of Years

: Street City State Zip Number of Years

Employment History
(Use Additional Employment History Information form if necessary
All applicants wishing to drive in interstate commerce must provide the following information on all employers during the preceding three years. You must
give the same information for all employers for whom you have driven a commercial vehicle seven years prior to the initial three years (total of ten year
employment record).
You are required to list the complete mailing address: street number and name, city, state and zip code.
Current or Last Employer Name: Phone #: ( ______ )
Street Address: City: State: Zip:
Position Held: From: To:
(month/year) (month/year)
Reasons for Leaving:
Were you subject to the FMCSRs** while employed: Yes No
Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirements
of 49 CFR Part 40: Yes No
*ACCOUNT FOR PERIOD BETWEEN JOBS – Include dates (month/year) and reason:

Second Last Employer Name: Phone #: ( ______ )

Street Address: City: State: Zip:
Position Held: From: To:
(month/year) (month/year)
Reasons for Leaving:
Were you subject to the FMCSRs** while employed: Yes No
Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirements of
49 CFR Part 40: Yes No
*ACCOUNT FOR PERIOD BETWEEN JOBS – Include dates (month/year) and reason:
Third Last Employer Name: Phone #: ( ______ )
Street Address: City: State: Zip:
Position Held: From: To:
(month/year) (month/year)
Reasons for Leaving:
Were you subject to the FMCSRs** while employed: Yes No
Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirements of
49 CFR Part 40: Yes No
*ACCOUNT FOR PERIOD BETWEEN JOBS – Include dates (month/year) and reason:
*Any gaps in employment and/or unemployment must be explained.
*Includes vehicles having a GVWR of 26,001 lbs. or more, vehicles designed to transport 16 or more passengers (including the driver), or any size vehicle
used to transport hazardous materials in a quantity requiring placarding.
**The Federal Motor Carrier Safety Regulations (FMCSRs) apply to anyone operating a motor vehicle on a highway in interstate commerce to transport
passengers or property when the vehicle: (1) weighs or has a GVWR of 10,001 pounds or more, (2) is designed or used to transport 9 or more passengers, OR
(3) is of any size and is used to transport hazardous materials in a quantity requiring placarding.
PLEASE COMPLETE NEXT PAGE
Copyright 2019 J. J. Keller & Associates, Inc., Neenah, WI • USA • 920-722-2848 FORM #3220 (519)
 USE THIS SHEET FOR ADDITIONAL EMPLOYMENT HISTORY INFORMATION
FOURTH LAST EMPLOYER: Name Phone Number ( )
Street Address City State Zip
Position Held From To
(month/year) (month/year)
Reasons for Leaving
Were you subject to the Federal Motor Carrier Safety Regulations** while employed? Yes No
Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the drug and alcohol testing
requirements of 49 CFR Part 40? Yes No
*ACCOUNT FOR PERIOD BETWEEN JOBS - Include dates (month/year) and reason
FIFTH LAST EMPLOYER: Name Phone Number ( )
Street Address City State Zip
Position Held From To
(month/year) (month/year)
Reasons for Leaving
Were you subject to the Federal Motor Carrier Safety Regulations** while employed? Yes No
Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the drug and alcohol testing
requirements of 49 CFR Part 40? Yes No
*ACCOUNT FOR PERIOD BETWEEN JOBS - Include dates (month/year) and reason
SIXTH LAST EMPLOYER: Name Phone Number ( )
Street Address City State Zip
Position Held From To
(month/year) (month/year)
Reasons for Leaving
Were you subject to the Federal Motor Carrier Safety Regulations** while employed? Yes No
Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the drug and alcohol testing
requirements of 49 CFR Part 40? Yes No
*ACCOUNT FOR PERIOD BETWEEN JOBS - Include dates (month/year) and reason
SEVENTH LAST EMPLOYER: Name Phone Number ( )
Street Address City State Zip
Position Held From To
(month/year) (month/year)
Reasons for Leaving
Were you subject to the Federal Motor Carrier Safety Regulations** while employed? Yes No
Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the drug and alcohol testing
requirements of 49 CFR Part 40? Yes No
*ACCOUNT FOR PERIOD BETWEEN JOBS - Include dates (month/year) and reason
EIGHTH LAST EMPLOYER: Name Phone Number ( )
Street Address City State Zip
Position Held From To
(month/year) (month/year)
Reasons for Leaving
Were you subject to the Federal Motor Carrier Safety Regulations** while employed? Yes No
Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the drug and alcohol testing
requirements of 49 CFR Part 40? Yes No
*ACCOUNT FOR PERIOD BETWEEN JOBS - Include dates (month/year) and reason
NINTH LAST EMPLOYER: Name Phone Number ( )
Street Address City State Zip
Position Held From To
(month/year) (month/year)
Reasons for Leaving
Were you subject to the Federal Motor Carrier Safety Regulations** while employed? Yes No
Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the drug and alcohol testing
requirements of 49 CFR Part 40? Yes No
*ACCOUNT FOR PERIOD BETWEEN JOBS - Include dates (month/year) and reason
TENTH LAST EMPLOYER: Name Phone Number ( )
Street Address City State Zip
Position Held From To
(month/year) (month/year)
Reasons for Leaving
Were you subject to the Federal Motor Carrier Safety Regulations** while employed? Yes No
Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the drug and alcohol testing
requirements of 49 CFR Part 40? Yes No
*ACCOUNT FOR PERIOD BETWEEN JOBS - Include dates (month/year) and reason
*Any gaps in employment and/or unemployment must be explained.
**The Federal Motor Carrier Safety Regulations apply to anyone operating a motor vehicle on a highway in interstate commerce to transport passengers or property when the vehicle:
(1) weighs or has a GVWR of 10,001 pounds or more, (2) is designed or used to transport more than 8 passengers (including the driver) for compensation; or (3) is designed or used to
transport more than 15 passengers, including the driver, and is not used to transport passengers for compensation; or (4) is of any size and is used to transport hazardous materials in a
quantity requiring placarding.
Copyright 2013 J. J. Keller & Associates, Inc.® All rights reserved. Neenah, WI • USA • 800-327-6868 • jjkeller.com • Printed in the United States 750-F-1 (Rev. 7/13)
 EXPERIENCE AND QUALIFICATION
Attach separate sheet if more space is needed.
Driving Experience
If no driving experience in the last 3 years, check here:
DATES APPROXIMATE
CLASS OF EQUIPMENT TYPE OF EQUIPMENT
FROM TO NUMBER OF MILES
Straight Truck Van Reefer Tank Flat

Tractor & Semi-Trailer Van Reefer Tank Flat

OR
Tractor – Two Trailers Van Reefer Tank Flat

Tractor – Three Trailers Van Reefer Tank Flat

Motorcoach - School Bus
N/A
(Greater than 8 passengers)
Motorcoach - School Bus
N/A
(Greater than 15 passengers)

Other: _________________________ Van Reefer Tank Flat

Accident History (3 years)

If no accidents in the last 3 years, check here:
DATE NATURE OF ACCIDENT NUMBER OF NUMBER OF HAZARDOUS
(Month/Year) (head-on, rear end, upset, etc.) FATALITIES INJURIES MATERIALS SPILL

Yes No

Yes No

Yes No

Traffic Convictions and Forfeitures (3 years)

If no traffic convictions and/or forfeitures in the last 3 years, check here:
DATE CONVICTED VIOLATION
STATE OF VIOLATION PENALTY
(Month/Year) (other than violations involving parking only)

License Information
Section 383.21 FMCSR states “No person who operates a commercial motor vehicle shall at any time have more than one driver’s
license”. I certify that I do not have more than one motor vehicle license, the information for which is listed below.

State License Number Expiration Date

A. Have you ever been denied a license, permit, or privilege to operate a motor vehicle: Yes No
If yes, give details:
B. Has any license, permit or privilege ever been suspended or revoked: Yes No
If yes, give details:

Applicant Certification
This certifies that this application was completed by me, and that all entries on it and information in it are true and complete to the best of
my knowledge.

Applicant’s Signature Date

This form is made available with the understanding that J. J. Keller & Associates, Inc. is not engaged in rendering legal, accounting, or other professional
services. J. J. Keller & Associates, Inc. assumes no responsibility for the use of this form, or any decision made by an employer which may violate local, state,
or federal law.
Copyright 2019 J. J. Keller & Associates, Inc., Neenah, WI • USA • 920-722-2848 FORM #3220 (2/19)
 Reset Form
SIDE 1 SAFETY PERFORMANCE HISTORY RECORDS REQUEST
RECIPIENT EMPLOYER: The individual identified in SECTION 1 below has indicated that you employ(ed) or use(d) them within
the last 3 years in a position that involved the operation of a commercial motor vehicle.
In accordance with 49 CFR §391.23, we are hereby requesting that you supply us with the Safety Performance History of this
individual. Under DOT rule §391.23(g), you must respond to this inquiry within 30 days of receipt.
Please complete SECTIONS 2 and 3 (as applicable) and return to the prospective employer shown in SECTION 1.
APPLICANT: Complete SECTION 1 and submit to prospective employer.
PROSPECTIVE EMPLOYER: Complete SECTION 4a and send form to current/previous employer. Upon receipt of completed
form, complete SECTION 4b and retain.

SECTION 1: TO BE COMPLETED BY PROSPECTIVE EMPLOYEE

I, (Print Name)
First, M.I., Last Social Security Number
hereby authorize:
Date of Birth

Previous Employer: Email:

Street: Telephone:

City, State, Zip: Fax No.:

To release this information in a written form that ensures confidentiality, such as fax, email, or letter, to:
J. J. Keller and Sterling on Behalf of
Prospective Employer: Sterling on behalf of: Allen Distribution

Attention: DOT Verifications Telephone: 833-631-2429

Street: 6150 Oak Tree Blvd., Suite 490

City, State, Zip: Independence, OH 44131

Prospective employer’s confidential fax number: 646-829-3534

Prospective employer’s confidential email address: verify.background@sterlingcheck.com

Applicant’s Signature Date

SECTION 2: TO BE COMPLETED BY PREVIOUS EMPLOYER

EMPLOYMENT VERIFICATION
The applicant named above was or is employed or used by us. Yes No
Employed as (job title) from (m/y) to (m/y)
Did they drive a motor vehicle for you? Yes No If yes, what type? Straight Truck Tractor-Semitrailer Bus
Cargo Tank Doubles/Triples Other (Specify)
Completed by:
Company:
Street:
City, State, Zip: Telephone:
Signature: Date:
Complete Section 3 on SIDE 2 before returning.

Copyright 2022 J. J. Keller & Associates, Inc. • Neenah, WI • JJKeller.com • (800) 327-6868 • Printed in the USA 9652 (Rev. 10/22)
SIDE 2 Employee Name: Date:
SECTION 3: TO BE COMPLETED BY PREVIOUS EMPLOYER
ACCIDENT HISTORY
Check here if there is no accident register data for this driver. Complete the following for any accidents included on your
accident register (§390.15(b)) that involved the applicant in the 3 years prior to the application date shown on SIDE 1.

Date Location No. of Injuries No. of Fatalities Hazmat Spill

1.
2.
3.
Please provide information concerning any other commercial motor vehicle accidents involving the applicant that were reported
to government agencies or insurers or retained under internal company policies:

SECTION 4a: TO BE COMPLETED BY PROSPECTIVE EMPLOYER

This form was (check one) Faxed to previous employer Mailed Emailed Other

By: Date:

Subsequent attempts to contact previous employer (§391.23(c)(1)):

SECTION 4 b: TO BE COMPLETED BY PROSPECTIVE EMPLOYER

Complete below when information is obtained.
Information received from:
Recorded by: Method: Fax Mail Email Telephone
Date: Other

Copyright 2022 J. J. Keller & Associates, Inc. • Neenah, WI • JJKeller.com • (800) 327-6868 • Printed in the USA 9652 (Rev. 10/22)
 Reset Form
SIDE 1 SAFETY PERFORMANCE HISTORY RECORDS REQUEST
RECIPIENT EMPLOYER: The individual identified in SECTION 1 below has indicated that you employ(ed) or use(d) them within
the last 3 years in a position that involved the operation of a commercial motor vehicle.
In accordance with 49 CFR §391.23, we are hereby requesting that you supply us with the Safety Performance History of this
individual. Under DOT rule §391.23(g), you must respond to this inquiry within 30 days of receipt.
Please complete SECTIONS 2 and 3 (as applicable) and return to the prospective employer shown in SECTION 1.
APPLICANT: Complete SECTION 1 and submit to prospective employer.
PROSPECTIVE EMPLOYER: Complete SECTION 4a and send form to current/previous employer. Upon receipt of completed
form, complete SECTION 4b and retain.

SECTION 1: TO BE COMPLETED BY PROSPECTIVE EMPLOYEE

I, (Print Name)
First, M.I., Last Social Security Number
hereby authorize:
Date of Birth

Previous Employer: Email:

Street: Telephone:

City, State, Zip: Fax No.:

To release this information in a written form that ensures confidentiality, such as fax, email, or letter, to:
J. J. Keller and Sterling on Behalf of
Prospective Employer: Sterling on behalf of: Allen Distribution

Attention: DOT Verifications Telephone: 833-631-2429

Street: 6150 Oak Tree Blvd., Suite 490

City, State, Zip: Independence, OH 44131

Prospective employer’s confidential fax number: 646-829-3534

Prospective employer’s confidential email address: verify.background@sterlingcheck.com

Applicant’s Signature Date

SECTION 2: TO BE COMPLETED BY PREVIOUS EMPLOYER

EMPLOYMENT VERIFICATION
The applicant named above was or is employed or used by us. Yes No
Employed as (job title) from (m/y) to (m/y)
Did they drive a motor vehicle for you? Yes No If yes, what type? Straight Truck Tractor-Semitrailer Bus
Cargo Tank Doubles/Triples Other (Specify)
Completed by:
Company:
Street:
City, State, Zip: Telephone:
Signature: Date:
Complete Section 3 on SIDE 2 before returning.

Copyright 2022 J. J. Keller & Associates, Inc. • Neenah, WI • JJKeller.com • (800) 327-6868 • Printed in the USA 9652 (Rev. 10/22)
SIDE 2 Employee Name: Date:
SECTION 3: TO BE COMPLETED BY PREVIOUS EMPLOYER
ACCIDENT HISTORY
Check here if there is no accident register data for this driver. Complete the following for any accidents included on your
accident register (§390.15(b)) that involved the applicant in the 3 years prior to the application date shown on SIDE 1.

Date Location No. of Injuries No. of Fatalities Hazmat Spill

1.
2.
3.
Please provide information concerning any other commercial motor vehicle accidents involving the applicant that were reported
to government agencies or insurers or retained under internal company policies:

SECTION 4a: TO BE COMPLETED BY PROSPECTIVE EMPLOYER

This form was (check one) Faxed to previous employer Mailed Emailed Other

By: Date:

Subsequent attempts to contact previous employer (§391.23(c)(1)):

SECTION 4 b: TO BE COMPLETED BY PROSPECTIVE EMPLOYER

Complete below when information is obtained.
Information received from:
Recorded by: Method: Fax Mail Email Telephone
Date: Other

Copyright 2022 J. J. Keller & Associates, Inc. • Neenah, WI • JJKeller.com • (800) 327-6868 • Printed in the USA 9652 (Rev. 10/22)
 Reset Form
SIDE 1 SAFETY PERFORMANCE HISTORY RECORDS REQUEST
RECIPIENT EMPLOYER: The individual identified in SECTION 1 below has indicated that you employ(ed) or use(d) them within
the last 3 years in a position that involved the operation of a commercial motor vehicle.
In accordance with 49 CFR §391.23, we are hereby requesting that you supply us with the Safety Performance History of this
individual. Under DOT rule §391.23(g), you must respond to this inquiry within 30 days of receipt.
Please complete SECTIONS 2 and 3 (as applicable) and return to the prospective employer shown in SECTION 1.
APPLICANT: Complete SECTION 1 and submit to prospective employer.
PROSPECTIVE EMPLOYER: Complete SECTION 4a and send form to current/previous employer. Upon receipt of completed
form, complete SECTION 4b and retain.

SECTION 1: TO BE COMPLETED BY PROSPECTIVE EMPLOYEE

I, (Print Name)
First, M.I., Last Social Security Number
hereby authorize:
Date of Birth

Previous Employer: Email:

Street: Telephone:

City, State, Zip: Fax No.:

To release this information in a written form that ensures confidentiality, such as fax, email, or letter, to:
J. J. Keller and Sterling on Behalf of
Prospective Employer: Sterling on behalf of: Allen Distribution

Attention: DOT Verifications Telephone: 833-631-2429

Street: 6150 Oak Tree Blvd., Suite 490

City, State, Zip: Independence, OH 44131

Prospective employer’s confidential fax number: 646-829-3534

Prospective employer’s confidential email address: verify.background@sterlingcheck.com

Applicant’s Signature Date

SECTION 2: TO BE COMPLETED BY PREVIOUS EMPLOYER

EMPLOYMENT VERIFICATION
The applicant named above was or is employed or used by us. Yes No
Employed as (job title) from (m/y) to (m/y)
Did they drive a motor vehicle for you? Yes No If yes, what type? Straight Truck Tractor-Semitrailer Bus
Cargo Tank Doubles/Triples Other (Specify)
Completed by:
Company:
Street:
City, State, Zip: Telephone:
Signature: Date:
Complete Section 3 on SIDE 2 before returning.

Copyright 2022 J. J. Keller & Associates, Inc. • Neenah, WI • JJKeller.com • (800) 327-6868 • Printed in the USA 9652 (Rev. 10/22)
SIDE 2 Employee Name: Date:
SECTION 3: TO BE COMPLETED BY PREVIOUS EMPLOYER
ACCIDENT HISTORY
Check here if there is no accident register data for this driver. Complete the following for any accidents included on your
accident register (§390.15(b)) that involved the applicant in the 3 years prior to the application date shown on SIDE 1.

Date Location No. of Injuries No. of Fatalities Hazmat Spill

1.
2.
3.
Please provide information concerning any other commercial motor vehicle accidents involving the applicant that were reported
to government agencies or insurers or retained under internal company policies:

SECTION 4a: TO BE COMPLETED BY PROSPECTIVE EMPLOYER

This form was (check one) Faxed to previous employer Mailed Emailed Other

By: Date:

Subsequent attempts to contact previous employer (§391.23(c)(1)):

SECTION 4 b: TO BE COMPLETED BY PROSPECTIVE EMPLOYER

Complete below when information is obtained.
Information received from:
Recorded by: Method: Fax Mail Email Telephone
Date: Other

Copyright 2022 J. J. Keller & Associates, Inc. • Neenah, WI • JJKeller.com • (800) 327-6868 • Printed in the USA 9652 (Rev. 10/22)
 Reset Form
SIDE 1 SAFETY PERFORMANCE HISTORY RECORDS REQUEST
RECIPIENT EMPLOYER: The individual identified in SECTION 1 below has indicated that you employ(ed) or use(d) them within
the last 3 years in a position that involved the operation of a commercial motor vehicle.
In accordance with 49 CFR §391.23, we are hereby requesting that you supply us with the Safety Performance History of this
individual. Under DOT rule §391.23(g), you must respond to this inquiry within 30 days of receipt.
Please complete SECTIONS 2 and 3 (as applicable) and return to the prospective employer shown in SECTION 1.
APPLICANT: Complete SECTION 1 and submit to prospective employer.
PROSPECTIVE EMPLOYER: Complete SECTION 4a and send form to current/previous employer. Upon receipt of completed
form, complete SECTION 4b and retain.

SECTION 1: TO BE COMPLETED BY PROSPECTIVE EMPLOYEE

I, (Print Name)
First, M.I., Last Social Security Number
hereby authorize:
Date of Birth

Previous Employer: Email:

Street: Telephone:

City, State, Zip: Fax No.:

To release this information in a written form that ensures confidentiality, such as fax, email, or letter, to:
J. J. Keller and Sterling on Behalf of
Prospective Employer: Sterling on behalf of: Allen Distribution

Attention: DOT Verifications Telephone: 833-631-2429

Street: 6150 Oak Tree Blvd., Suite 490

City, State, Zip: Independence, OH 44131

Prospective employer’s confidential fax number: 646-829-3534

Prospective employer’s confidential email address: verify.background@sterlingcheck.com

Applicant’s Signature Date

SECTION 2: TO BE COMPLETED BY PREVIOUS EMPLOYER

EMPLOYMENT VERIFICATION
The applicant named above was or is employed or used by us. Yes No
Employed as (job title) from (m/y) to (m/y)
Did they drive a motor vehicle for you? Yes No If yes, what type? Straight Truck Tractor-Semitrailer Bus
Cargo Tank Doubles/Triples Other (Specify)
Completed by:
Company:
Street:
City, State, Zip: Telephone:
Signature: Date:
Complete Section 3 on SIDE 2 before returning.

Copyright 2022 J. J. Keller & Associates, Inc. • Neenah, WI • JJKeller.com • (800) 327-6868 • Printed in the USA 9652 (Rev. 10/22)
SIDE 2 Employee Name: Date:
SECTION 3: TO BE COMPLETED BY PREVIOUS EMPLOYER
ACCIDENT HISTORY
Check here if there is no accident register data for this driver. Complete the following for any accidents included on your
accident register (§390.15(b)) that involved the applicant in the 3 years prior to the application date shown on SIDE 1.

Date Location No. of Injuries No. of Fatalities Hazmat Spill

1.
2.
3.
Please provide information concerning any other commercial motor vehicle accidents involving the applicant that were reported
to government agencies or insurers or retained under internal company policies:

SECTION 4a: TO BE COMPLETED BY PROSPECTIVE EMPLOYER

This form was (check one) Faxed to previous employer Mailed Emailed Other

By: Date:

Subsequent attempts to contact previous employer (§391.23(c)(1)):

SECTION 4 b: TO BE COMPLETED BY PROSPECTIVE EMPLOYER

Complete below when information is obtained.
Information received from:
Recorded by: Method: Fax Mail Email Telephone
Date: Other

Copyright 2022 J. J. Keller & Associates, Inc. • Neenah, WI • JJKeller.com • (800) 327-6868 • Printed in the USA 9652 (Rev. 10/22)
 Reset Form
SIDE 1 SAFETY PERFORMANCE HISTORY RECORDS REQUEST
RECIPIENT EMPLOYER: The individual identified in SECTION 1 below has indicated that you employ(ed) or use(d) them within
the last 3 years in a position that involved the operation of a commercial motor vehicle.
In accordance with 49 CFR §391.23, we are hereby requesting that you supply us with the Safety Performance History of this
individual. Under DOT rule §391.23(g), you must respond to this inquiry within 30 days of receipt.
Please complete SECTIONS 2 and 3 (as applicable) and return to the prospective employer shown in SECTION 1.
APPLICANT: Complete SECTION 1 and submit to prospective employer.
PROSPECTIVE EMPLOYER: Complete SECTION 4a and send form to current/previous employer. Upon receipt of completed
form, complete SECTION 4b and retain.

SECTION 1: TO BE COMPLETED BY PROSPECTIVE EMPLOYEE

I, (Print Name)
First, M.I., Last Social Security Number
hereby authorize:
Date of Birth

Previous Employer: Email:

Street: Telephone:

City, State, Zip: Fax No.:

To release this information in a written form that ensures confidentiality, such as fax, email, or letter, to:
J. J. Keller and Sterling on Behalf of
Prospective Employer: Sterling on behalf of: Allen Distribution

Attention: DOT Verifications Telephone: 833-631-2429

Street: 6150 Oak Tree Blvd., Suite 490

City, State, Zip: Independence, OH 44131

Prospective employer’s confidential fax number: 646-829-3534

Prospective employer’s confidential email address: verify.background@sterlingcheck.com

Applicant’s Signature Date

SECTION 2: TO BE COMPLETED BY PREVIOUS EMPLOYER

EMPLOYMENT VERIFICATION
The applicant named above was or is employed or used by us. Yes No
Employed as (job title) from (m/y) to (m/y)
Did they drive a motor vehicle for you? Yes No If yes, what type? Straight Truck Tractor-Semitrailer Bus
Cargo Tank Doubles/Triples Other (Specify)
Completed by:
Company:
Street:
City, State, Zip: Telephone:
Signature: Date:
Complete Section 3 on SIDE 2 before returning.

Copyright 2022 J. J. Keller & Associates, Inc. • Neenah, WI • JJKeller.com • (800) 327-6868 • Printed in the USA 9652 (Rev. 10/22)
SIDE 2 Employee Name: Date:
SECTION 3: TO BE COMPLETED BY PREVIOUS EMPLOYER
ACCIDENT HISTORY
Check here if there is no accident register data for this driver. Complete the following for any accidents included on your
accident register (§390.15(b)) that involved the applicant in the 3 years prior to the application date shown on SIDE 1.

Date Location No. of Injuries No. of Fatalities Hazmat Spill

1.
2.
3.
Please provide information concerning any other commercial motor vehicle accidents involving the applicant that were reported
to government agencies or insurers or retained under internal company policies:

SECTION 4a: TO BE COMPLETED BY PROSPECTIVE EMPLOYER

This form was (check one) Faxed to previous employer Mailed Emailed Other

By: Date:

Subsequent attempts to contact previous employer (§391.23(c)(1)):

SECTION 4 b: TO BE COMPLETED BY PROSPECTIVE EMPLOYER

Complete below when information is obtained.
Information received from:
Recorded by: Method: Fax Mail Email Telephone
Date: Other

Copyright 2022 J. J. Keller & Associates, Inc. • Neenah, WI • JJKeller.com • (800) 327-6868 • Printed in the USA 9652 (Rev. 10/22)
 Reset Form
SIDE 1 SAFETY PERFORMANCE HISTORY RECORDS REQUEST
RECIPIENT EMPLOYER: The individual identified in SECTION 1 below has indicated that you employ(ed) or use(d) them within
the last 3 years in a position that involved the operation of a commercial motor vehicle.
In accordance with 49 CFR §391.23, we are hereby requesting that you supply us with the Safety Performance History of this
individual. Under DOT rule §391.23(g), you must respond to this inquiry within 30 days of receipt.
Please complete SECTIONS 2 and 3 (as applicable) and return to the prospective employer shown in SECTION 1.
APPLICANT: Complete SECTION 1 and submit to prospective employer.
PROSPECTIVE EMPLOYER: Complete SECTION 4a and send form to current/previous employer. Upon receipt of completed
form, complete SECTION 4b and retain.

SECTION 1: TO BE COMPLETED BY PROSPECTIVE EMPLOYEE

I, (Print Name)
First, M.I., Last Social Security Number
hereby authorize:
Date of Birth

Previous Employer: Email:

Street: Telephone:

City, State, Zip: Fax No.:

To release this information in a written form that ensures confidentiality, such as fax, email, or letter, to:
J. J. Keller and Sterling on Behalf of
Prospective Employer: Sterling on behalf of: Allen Distribution

Attention: DOT Verifications Telephone: 833-631-2429

Street: 6150 Oak Tree Blvd., Suite 490

City, State, Zip: Independence, OH 44131

Prospective employer’s confidential fax number: 646-829-3534

Prospective employer’s confidential email address: verify.background@sterlingcheck.com

Applicant’s Signature Date

SECTION 2: TO BE COMPLETED BY PREVIOUS EMPLOYER

EMPLOYMENT VERIFICATION
The applicant named above was or is employed or used by us. Yes No
Employed as (job title) from (m/y) to (m/y)
Did they drive a motor vehicle for you? Yes No If yes, what type? Straight Truck Tractor-Semitrailer Bus
Cargo Tank Doubles/Triples Other (Specify)
Completed by:
Company:
Street:
City, State, Zip: Telephone:
Signature: Date:
Complete Section 3 on SIDE 2 before returning.

Copyright 2022 J. J. Keller & Associates, Inc. • Neenah, WI • JJKeller.com • (800) 327-6868 • Printed in the USA 9652 (Rev. 10/22)
SIDE 2 Employee Name: Date:
SECTION 3: TO BE COMPLETED BY PREVIOUS EMPLOYER
ACCIDENT HISTORY
Check here if there is no accident register data for this driver. Complete the following for any accidents included on your
accident register (§390.15(b)) that involved the applicant in the 3 years prior to the application date shown on SIDE 1.

Date Location No. of Injuries No. of Fatalities Hazmat Spill

1.
2.
3.
Please provide information concerning any other commercial motor vehicle accidents involving the applicant that were reported
to government agencies or insurers or retained under internal company policies:

SECTION 4a: TO BE COMPLETED BY PROSPECTIVE EMPLOYER

This form was (check one) Faxed to previous employer Mailed Emailed Other

By: Date:

Subsequent attempts to contact previous employer (§391.23(c)(1)):

SECTION 4 b: TO BE COMPLETED BY PROSPECTIVE EMPLOYER

Complete below when information is obtained.
Information received from:
Recorded by: Method: Fax Mail Email Telephone
Date: Other

Copyright 2022 J. J. Keller & Associates, Inc. • Neenah, WI • JJKeller.com • (800) 327-6868 • Printed in the USA 9652 (Rev. 10/22)
 Reset Form
SIDE 1 SAFETY PERFORMANCE HISTORY RECORDS REQUEST
RECIPIENT EMPLOYER: The individual identified in SECTION 1 below has indicated that you employ(ed) or use(d) them within
the last 3 years in a position that involved the operation of a commercial motor vehicle.
In accordance with 49 CFR §391.23, we are hereby requesting that you supply us with the Safety Performance History of this
individual. Under DOT rule §391.23(g), you must respond to this inquiry within 30 days of receipt.
Please complete SECTIONS 2 and 3 (as applicable) and return to the prospective employer shown in SECTION 1.
APPLICANT: Complete SECTION 1 and submit to prospective employer.
PROSPECTIVE EMPLOYER: Complete SECTION 4a and send form to current/previous employer. Upon receipt of completed
form, complete SECTION 4b and retain.

SECTION 1: TO BE COMPLETED BY PROSPECTIVE EMPLOYEE

I, (Print Name)
First, M.I., Last Social Security Number
hereby authorize:
Date of Birth

Previous Employer: Email:

Street: Telephone:

City, State, Zip: Fax No.:

To release this information in a written form that ensures confidentiality, such as fax, email, or letter, to:
J. J. Keller and Sterling on Behalf of
Prospective Employer: Sterling on behalf of: Allen Distribution

Attention: DOT Verifications Telephone: 833-631-2429

Street: 6150 Oak Tree Blvd., Suite 490

City, State, Zip: Independence, OH 44131

Prospective employer’s confidential fax number: 646-829-3534

Prospective employer’s confidential email address: verify.background@sterlingcheck.com

Applicant’s Signature Date

SECTION 2: TO BE COMPLETED BY PREVIOUS EMPLOYER

EMPLOYMENT VERIFICATION
The applicant named above was or is employed or used by us. Yes No
Employed as (job title) from (m/y) to (m/y)
Did they drive a motor vehicle for you? Yes No If yes, what type? Straight Truck Tractor-Semitrailer Bus
Cargo Tank Doubles/Triples Other (Specify)
Completed by:
Company:
Street:
City, State, Zip: Telephone:
Signature: Date:
Complete Section 3 on SIDE 2 before returning.

Copyright 2022 J. J. Keller & Associates, Inc. • Neenah, WI • JJKeller.com • (800) 327-6868 • Printed in the USA 9652 (Rev. 10/22)
SIDE 2 Employee Name: Date:
SECTION 3: TO BE COMPLETED BY PREVIOUS EMPLOYER
ACCIDENT HISTORY
Check here if there is no accident register data for this driver. Complete the following for any accidents included on your
accident register (§390.15(b)) that involved the applicant in the 3 years prior to the application date shown on SIDE 1.

Date Location No. of Injuries No. of Fatalities Hazmat Spill

1.
2.
3.
Please provide information concerning any other commercial motor vehicle accidents involving the applicant that were reported
to government agencies or insurers or retained under internal company policies:

SECTION 4a: TO BE COMPLETED BY PROSPECTIVE EMPLOYER

This form was (check one) Faxed to previous employer Mailed Emailed Other

By: Date:

Subsequent attempts to contact previous employer (§391.23(c)(1)):

SECTION 4 b: TO BE COMPLETED BY PROSPECTIVE EMPLOYER

Complete below when information is obtained.
Information received from:
Recorded by: Method: Fax Mail Email Telephone
Date: Other

Copyright 2022 J. J. Keller & Associates, Inc. • Neenah, WI • JJKeller.com • (800) 327-6868 • Printed in the USA 9652 (Rev. 10/22)
 Reset Form
SIDE 1 SAFETY PERFORMANCE HISTORY RECORDS REQUEST
RECIPIENT EMPLOYER: The individual identified in SECTION 1 below has indicated that you employ(ed) or use(d) them within
the last 3 years in a position that involved the operation of a commercial motor vehicle.
In accordance with 49 CFR §391.23, we are hereby requesting that you supply us with the Safety Performance History of this
individual. Under DOT rule §391.23(g), you must respond to this inquiry within 30 days of receipt.
Please complete SECTIONS 2 and 3 (as applicable) and return to the prospective employer shown in SECTION 1.
APPLICANT: Complete SECTION 1 and submit to prospective employer.
PROSPECTIVE EMPLOYER: Complete SECTION 4a and send form to current/previous employer. Upon receipt of completed
form, complete SECTION 4b and retain.

SECTION 1: TO BE COMPLETED BY PROSPECTIVE EMPLOYEE

I, (Print Name)
First, M.I., Last Social Security Number
hereby authorize:
Date of Birth

Previous Employer: Email:

Street: Telephone:

City, State, Zip: Fax No.:

To release this information in a written form that ensures confidentiality, such as fax, email, or letter, to:
J. J. Keller and Sterling on Behalf of
Prospective Employer: Sterling on behalf of: Allen Distribution

Attention: DOT Verifications Telephone: 833-631-2429

Street: 6150 Oak Tree Blvd., Suite 490

City, State, Zip: Independence, OH 44131

Prospective employer’s confidential fax number: 646-829-3534

Prospective employer’s confidential email address: verify.background@sterlingcheck.com

Applicant’s Signature Date

SECTION 2: TO BE COMPLETED BY PREVIOUS EMPLOYER

EMPLOYMENT VERIFICATION
The applicant named above was or is employed or used by us. Yes No
Employed as (job title) from (m/y) to (m/y)
Did they drive a motor vehicle for you? Yes No If yes, what type? Straight Truck Tractor-Semitrailer Bus
Cargo Tank Doubles/Triples Other (Specify)
Completed by:
Company:
Street:
City, State, Zip: Telephone:
Signature: Date:
Complete Section 3 on SIDE 2 before returning.

Copyright 2022 J. J. Keller & Associates, Inc. • Neenah, WI • JJKeller.com • (800) 327-6868 • Printed in the USA 9652 (Rev. 10/22)
SIDE 2 Employee Name: Date:
SECTION 3: TO BE COMPLETED BY PREVIOUS EMPLOYER
ACCIDENT HISTORY
Check here if there is no accident register data for this driver. Complete the following for any accidents included on your
accident register (§390.15(b)) that involved the applicant in the 3 years prior to the application date shown on SIDE 1.

Date Location No. of Injuries No. of Fatalities Hazmat Spill

1.
2.
3.
Please provide information concerning any other commercial motor vehicle accidents involving the applicant that were reported
to government agencies or insurers or retained under internal company policies:

SECTION 4a: TO BE COMPLETED BY PROSPECTIVE EMPLOYER

This form was (check one) Faxed to previous employer Mailed Emailed Other

By: Date:

Subsequent attempts to contact previous employer (§391.23(c)(1)):

SECTION 4 b: TO BE COMPLETED BY PROSPECTIVE EMPLOYER

Complete below when information is obtained.
Information received from:
Recorded by: Method: Fax Mail Email Telephone
Date: Other

Copyright 2022 J. J. Keller & Associates, Inc. • Neenah, WI • JJKeller.com • (800) 327-6868 • Printed in the USA 9652 (Rev. 10/22)
 Reset Form
SIDE 1 SAFETY PERFORMANCE HISTORY RECORDS REQUEST
RECIPIENT EMPLOYER: The individual identified in SECTION 1 below has indicated that you employ(ed) or use(d) them within
the last 3 years in a position that involved the operation of a commercial motor vehicle.
In accordance with 49 CFR §391.23, we are hereby requesting that you supply us with the Safety Performance History of this
individual. Under DOT rule §391.23(g), you must respond to this inquiry within 30 days of receipt.
Please complete SECTIONS 2 and 3 (as applicable) and return to the prospective employer shown in SECTION 1.
APPLICANT: Complete SECTION 1 and submit to prospective employer.
PROSPECTIVE EMPLOYER: Complete SECTION 4a and send form to current/previous employer. Upon receipt of completed
form, complete SECTION 4b and retain.

SECTION 1: TO BE COMPLETED BY PROSPECTIVE EMPLOYEE

I, (Print Name)
First, M.I., Last Social Security Number
hereby authorize:
Date of Birth

Previous Employer: Email:

Street: Telephone:

City, State, Zip: Fax No.:

To release this information in a written form that ensures confidentiality, such as fax, email, or letter, to:
J. J. Keller and Sterling on Behalf of
Prospective Employer: Sterling on behalf of: Allen Distribution

Attention: DOT Verifications Telephone: 833-631-2429

Street: 6150 Oak Tree Blvd., Suite 490

City, State, Zip: Independence, OH 44131

Prospective employer’s confidential fax number: 646-829-3534

Prospective employer’s confidential email address: verify.background@sterlingcheck.com

Applicant’s Signature Date

SECTION 2: TO BE COMPLETED BY PREVIOUS EMPLOYER

EMPLOYMENT VERIFICATION
The applicant named above was or is employed or used by us. Yes No
Employed as (job title) from (m/y) to (m/y)
Did they drive a motor vehicle for you? Yes No If yes, what type? Straight Truck Tractor-Semitrailer Bus
Cargo Tank Doubles/Triples Other (Specify)
Completed by:
Company:
Street:
City, State, Zip: Telephone:
Signature: Date:
Complete Section 3 on SIDE 2 before returning.

Copyright 2022 J. J. Keller & Associates, Inc. • Neenah, WI • JJKeller.com • (800) 327-6868 • Printed in the USA 9652 (Rev. 10/22)
SIDE 2 Employee Name: Date:
SECTION 3: TO BE COMPLETED BY PREVIOUS EMPLOYER
ACCIDENT HISTORY
Check here if there is no accident register data for this driver. Complete the following for any accidents included on your
accident register (§390.15(b)) that involved the applicant in the 3 years prior to the application date shown on SIDE 1.

Date Location No. of Injuries No. of Fatalities Hazmat Spill

1.
2.
3.
Please provide information concerning any other commercial motor vehicle accidents involving the applicant that were reported
to government agencies or insurers or retained under internal company policies:

SECTION 4a: TO BE COMPLETED BY PROSPECTIVE EMPLOYER

This form was (check one) Faxed to previous employer Mailed Emailed Other

By: Date:

Subsequent attempts to contact previous employer (§391.23(c)(1)):

SECTION 4 b: TO BE COMPLETED BY PROSPECTIVE EMPLOYER

Complete below when information is obtained.
Information received from:
Recorded by: Method: Fax Mail Email Telephone
Date: Other

Copyright 2022 J. J. Keller & Associates, Inc. • Neenah, WI • JJKeller.com • (800) 327-6868 • Printed in the USA 9652 (Rev. 10/22)
 Reset Form
SIDE 1 SAFETY PERFORMANCE HISTORY RECORDS REQUEST
RECIPIENT EMPLOYER: The individual identified in SECTION 1 below has indicated that you employ(ed) or use(d) them within
the last 3 years in a position that involved the operation of a commercial motor vehicle.
In accordance with 49 CFR §391.23, we are hereby requesting that you supply us with the Safety Performance History of this
individual. Under DOT rule §391.23(g), you must respond to this inquiry within 30 days of receipt.
Please complete SECTIONS 2 and 3 (as applicable) and return to the prospective employer shown in SECTION 1.
APPLICANT: Complete SECTION 1 and submit to prospective employer.
PROSPECTIVE EMPLOYER: Complete SECTION 4a and send form to current/previous employer. Upon receipt of completed
form, complete SECTION 4b and retain.

SECTION 1: TO BE COMPLETED BY PROSPECTIVE EMPLOYEE

I, (Print Name)
First, M.I., Last Social Security Number
hereby authorize:
Date of Birth

Previous Employer: Email:

Street: Telephone:

City, State, Zip: Fax No.:

To release this information in a written form that ensures confidentiality, such as fax, email, or letter, to:
J. J. Keller and Sterling on Behalf of
Prospective Employer: Sterling on behalf of: Allen Distribution

Attention: DOT Verifications Telephone: 833-631-2429

Street: 6150 Oak Tree Blvd., Suite 490

City, State, Zip: Independence, OH 44131

Prospective employer’s confidential fax number: 646-829-3534

Prospective employer’s confidential email address: verify.background@sterlingcheck.com

Applicant’s Signature Date

SECTION 2: TO BE COMPLETED BY PREVIOUS EMPLOYER

EMPLOYMENT VERIFICATION
The applicant named above was or is employed or used by us. Yes No
Employed as (job title) from (m/y) to (m/y)
Did they drive a motor vehicle for you? Yes No If yes, what type? Straight Truck Tractor-Semitrailer Bus
Cargo Tank Doubles/Triples Other (Specify)
Completed by:
Company:
Street:
City, State, Zip: Telephone:
Signature: Date:
Complete Section 3 on SIDE 2 before returning.

Copyright 2022 J. J. Keller & Associates, Inc. • Neenah, WI • JJKeller.com • (800) 327-6868 • Printed in the USA 9652 (Rev. 10/22)
SIDE 2 Employee Name: Date:
SECTION 3: TO BE COMPLETED BY PREVIOUS EMPLOYER
ACCIDENT HISTORY
Check here if there is no accident register data for this driver. Complete the following for any accidents included on your
accident register (§390.15(b)) that involved the applicant in the 3 years prior to the application date shown on SIDE 1.

Date Location No. of Injuries No. of Fatalities Hazmat Spill

1.
2.
3.
Please provide information concerning any other commercial motor vehicle accidents involving the applicant that were reported
to government agencies or insurers or retained under internal company policies:

SECTION 4a: TO BE COMPLETED BY PROSPECTIVE EMPLOYER

This form was (check one) Faxed to previous employer Mailed Emailed Other

By: Date:

Subsequent attempts to contact previous employer (§391.23(c)(1)):

SECTION 4 b: TO BE COMPLETED BY PROSPECTIVE EMPLOYER

Complete below when information is obtained.
Information received from:
Recorded by: Method: Fax Mail Email Telephone
Date: Other

Copyright 2022 J. J. Keller & Associates, Inc. • Neenah, WI • JJKeller.com • (800) 327-6868 • Printed in the USA 9652 (Rev. 10/22)
Sample documents should NOT be construed as legal advice, guidance or counsel. Employers should consult their own
attorney about their compliance responsibilities under the Fair Credit Reporting Act and applicable state law. J.J. Keller &
Associates, Inc. expressly disclaims any warranties or responsibility or damages associated with or arising out of
information provided. Employers seeking credit reports must provide additional notices pursuant to state law.

ACKNOWLEDGMENT AND AUTHORIZATION FOR BACKGROUND CHECK

I acknowledge receipt of the separate document entitled DISCLOSURE REGARDING BACKGROUND
INVESTIGATION, DISCLOSURE REGARDING INVESTIGATIVE BACKGROUND INVESTIGATION and A SUMMARY
OF YOUR RIGHTS UNDER THE FAIR CREDIT REPORTING ACT and certify that I have read and understand both of
those documents. I hereby authorize the obtaining of “consumer reports” (i.e. driving records, criminal history, social
security verification, and/or education history) and/or “investigative consumer reports” (i.e. employment and/or education
verification) by EMPLOYER (“Employer”) at any time after receipt of this authorization and throughout my employment, if
applicable. To this end, I hereby authorize, without reservation, any law enforcement agency, administrator, state or
federal agency, institution, school or university (public or private), information service bureau, employer, or insurance
company to furnish any and all background information requested by J. J. Keller & Associates, Inc., PO Box 368,
Neenah, WI 54957-0368, (877)-564-2333, www.jjkeller.com and/or Employer. I agree that a facsimile (“fax”), electronic
or photographic copy of this Authorization shall be as valid as the original.

Allen Distribution
Employer Name*: (“Employer”)

Last Name*: First*: Middle*:

Date of Birth*: Social Security Number (SSN):

Address*:

Email Address*:

Signature*: Date*:

*Required Information

1
THE BELOW DISCLOSURE AND AUTHORIZATION LANGUAGE IS FOR MANDATORY USE BY ALL
ACCOUNT HOLDERS

IMPORTANT DISCLOSURE
REGARDING BACKGROUND REPORTS FROM THE PSP Online Service
Allen Distribution
In connection with your application for employment with _____________________________ (“Prospective Employer”), Prospective
Employer, its employees, agents or contractors may obtain one or more reports regarding your driving, and safety inspection history
from the Federal Motor Carrier Safety Administration (FMCSA).

When the application for employment is submitted in person, if the Prospective Employer uses any information it obtains from FMCSA
in a decision to not hire you or to make any other adverse employment decision regarding you, the Prospective Employer will provide
you with a copy of the report upon which its decision was based and a written summary of your rights under the Fair Credit Reporting
Act before taking any final adverse action. If any final adverse action is taken against you based upon your driving history or safety
report, the Prospective Employer will notify you that the action has been taken and that the action was based in part or in whole on this
report.

When the application for employment is submitted by mail, telephone, computer, or other similar means, if the Prospective Employer
uses any information it obtains from FMCSA in a decision to not hire you or to make any other adverse employment decision regarding
you, the Prospective Employer must provide you within three business days of taking adverse action oral, written or electronic
notification: that adverse action has been taken based in whole or in part on information obtained from FMCSA; the name, address, and
the toll free telephone number of FMCSA; that the FMCSA did not make the decision to take the adverse action and is unable to provide
you the specific reasons why the adverse action was taken; and that you may, upon providing proper identification, request a free copy
of the report and may dispute with the FMCSA the accuracy or completeness of any information or report. If you request a copy of a
driver record from the Prospective Employer who procured the report, then, within 3 business days of receiving your request, together
with proper identification, the Prospective Employer must send or provide to you a copy of your report and a summary of your rights
under the Fair Credit Reporting Act.

Neither the Prospective Employer nor the FMCSA contractor supplying the crash and safety information has the capability to correct
any safety data that appears to be incorrect. You may challenge the accuracy of the data by submitting a request to
https://dataqs.fmcsa.dot.gov. If you challenge crash or inspection information reported by a State, FMCSA cannot change or correct this
data. Your request will be forwarded by the DataQs system to the appropriate State for adjudication.

Any crash or inspection in which you were involved will display on your PSP report. Since the PSP report does not report, or assign, or
imply fault, it will include all Commercial Motor Vehicle (CMV) crashes where you were a driver or co-driver and where those crashes
were reported to FMCSA, regardless of fault. Similarly, all inspections, with or without violations, appear on the PSP report. State
citations associated with Federal Motor Carrier Safety Regulations (FMCSR) violations that have been adjudicated by a court of law
will also appear, and remain, on a PSP report.

The Prospective Employer cannot obtain background reports from FMCSA without your authorization.

AUTHORIZATION
If you agree that the Prospective Employer may obtain such background reports, please read the following and sign below:
Allen Distribution
I authorize _______________________ (“Prospective Employer”) to access the FMCSA Pre-Employment Screening Program (PSP)
system to seek information regarding my commercial driving safety record and information regarding my safety inspection history. I
understand that I am authorizing the release of safety performance information including crash data from the previous five (5) years
and inspection history from the previous three (3) years. I understand and acknowledge that this release of information may assist the
Prospective Employer to make a determination regarding my suitability as an employee.

I further understand that neither the Prospective Employer nor the FMCSA contractor supplying the crash and safety information has
the capability to correct any safety data that appears to be incorrect. I understand I may challenge the accuracy of the data by
submitting a request to https://dataqs.fmcsa.dot.gov. If I challenge crash or inspection information reported by a State, FMCSA cannot
change or correct this data. I understand my request will be forwarded by the DataQs system to the appropriate State for adjudication.

I understand that any crash or inspection in which I was involved will display on my PSP report. Since the PSP report does not report,
or assign, or imply fault, I acknowledge it will include all CMV crashes where I was a driver or co-driver and where those crashes
were reported to FMCSA, regardless of fault. Similarly, I understand all inspections, with or without violations, will appear on my
PSP report, and State citations associated with FMCSR violations that have been adjudicated by a court of law will also appear, and
remain, on my PSP report.
I have read the above Disclosure Regarding Background Reports provided to me by Prospective Employer and I understand that if I
sign this Disclosure and Authorization, Prospective Employer may obtain a report of my crash and inspection history. I hereby
authorize Prospective Employer and its employees, authorized agents, and/or affiliates to obtain the information authorized above.

Date: __________________________ _______________________________________

Signature

___________________________________________

Name (Please Print)

NOTICE: This form is made available to monthly account holders by NIC on behalf of the U.S. Department of Transportation,
Federal Motor Carrier Safety Administration (FMCSA). Account holders are required by federal law to obtain an Applicant’s written
or electronic consent prior to accessing the Applicant’s PSP report. Further, account holders are required by FMCSA to use the
language contained in this Disclosure and Authorization form to obtain an Applicant’s consent. The language must be used in whole,
exactly as provided. Further, the language on this form must exist as one stand-alone document. The language may NOT be included
with other consent forms or any other language.

NOTICE: The prospective employment concept referenced in this form contemplates the definition of “employee” contained at 49
C.F.R. 383.5.

LAST UPDATED 2/11/2016

 Consent to Conduct Queries of the FMCSA CDL D&A Clearinghouse
As a condition of and for the duration of my employment with ______________________________________
Allen Distribution (“Company”), I,
(Company)
____________________________________, do hereby consent to allow “company” and/or it’s Third Party Administrator, J. J. Keller
(Driver Name)
& Associates, Inc., PO Box 368, Neenah, WI 54957-0368, (877)-564-2333, www.jjkeller.com to perform full and limited queries of and
to obtain information from the FMCSA Commercial Driver’s License Drug and Alcohol Clearinghouse (Clearinghouse) about me,
including any drug or alcohol violation information about me in the Clearinghouse.

I understand that queries will be conducted at least on an annual basis in accordance with FMCSA regulations.

Additionally, I understand that if I fail or refuse to provide timely consent for a query of the Clearinghouse, the Company must prohibit
me from performing safety-sensitive functions, including driving a commercial motor vehicle, as required by FMCSA’s drug and alcohol
program regulations.

CDL #: ___________________________________ State of Issuance: ________________ Date of Birth: _______________________

Driver’s Signature: ____________________________________________________ Date: ___________________________________

FMCSA D&A Testing Clearinghouse Driver Registration Instructions

Creating a Login.gov Account
1. Go to https://clearinghouse.fmcsa.dot.gov/register and click on “Go to login.gov” to create a login.gov account
2. Click “Create an account”
3. Enter your email address and click submit
4. Check your email and open the email from no-reply@login.gov with the subject Confirm your email
5. Click Confirm email address
6. Create a password (must be 12 + characters long and “strong enough” to continue), click “Continue”
7. Select an option to authenticate your account (phone via text or call; authentication application; government employee; or I
don’t have any of the above in which case you will be given 10 backup codes to keep in a secure place)
a. Best option is to utilize a cell phone with text first
8. Enter the security code you are sent within 10 minutes in the “One-time security code” box and click submit
9. You will be prompted to set up a second authentication method – repeat steps 7 and 8. You’ll only use one method to sign in.
a. Best option is to use a land line here
i. Note: if you utilize a land line you will need to be next to it to answer and get the code as soon as you click
on this option.
10. Click continue and then continue under “You can now sign in to the FMCSA Drug & Alcohol Clearinghouse”
Register for Clearinghouse (Start Here if you already have a login.gov account)
1. Login with email and password if you already have a login.gov account: https://clearinghouse.fmcsa.dot.gov/
2. Select your role – Driver
3. Enter your contact information and your preferred method of contact (email is advisable as notifications are time-sensitive) and
click next
a. Note: if you select U.S. Mail you will be asked to confirm this selection
4. Enter CDL information and click verify – this info will be verified against the information in the CDLIS
5. You will receive a “Success! We have verified your CDL information” when it’s been verified. Click next
6. Check box to accept terms and conditions and click I Agree
7. Registration Complete

Copyright 2019 J. J. Keller & Associates, Inc.

 Addendum to Company DOT D&A Testing Policy
Beginning January 6, 2020, the company will enforce the following provisions of the FMCSA D&A Testing Clearinghouse as per 49 CFR Part
382 Subpart G:
Commercial Driver's License Drug and Alcohol Clearinghouse (Clearinghouse) means the FMCSA database that subpart G of this part
requires employers and service agents to report information to, and to query, regarding drivers who are subject to the DOT controlled
substance and alcohol testing regulations.
Violation Reporting - The following personal information collected and maintained under this part by the company, and/or its C/TPA shall be
reported to the Clearinghouse:
 A verified positive, adulterated, or substituted drug test result;
 An alcohol confirmation test with a concentration of 0.04 or higher;
 A refusal to submit to any test required by subpart C of this part;
 An employer's report of actual knowledge, as defined at §382.107:
o On duty alcohol use pursuant to §382.205;
o Pre-duty alcohol use pursuant to §382.207;
o Alcohol use following an accident pursuant to §382.209; and
o Controlled substance use pursuant to §382.213;
 A substance abuse professional (SAP as defined in §40.3 of this title) report of the successful completion of the return-to-duty
process;
 A negative return-to-duty test; and
 An employer's report of completion of follow-up testing.
Pre-Employment Query - All driver applicants will be required to give specific consent through the Clearinghouse in order for the company
and/or its C/TPA to conduct a full query to the Clearinghouse in order to obtain information about whether the driver: has a verified positive,
adulterated, or substituted controlled substances test result; has an alcohol confirmation test with a concentration of 0.04 or higher; has
refused to submit to a test in violation of §382.211; or that an employer has reported actual knowledge, as defined at §382.107, that the driver
used alcohol on duty in violation of §382.205, used alcohol before duty in violation of §382.207, used alcohol following an accident in violation
of §382.209, or used a controlled substance, in violation of §382.213. The company will not employ a driver subject to controlled substances
and alcohol testing under this part to perform a safety-sensitive function (SSF) without first conducting a pre-employment query of the
Clearinghouse. Further, the company will not permit a driver to perform SSFs without first obtaining specific consent through the
Clearinghouse from the driver applicant.
Annual Query is required – The company and/or its C/TPA will conduct a limited query at least once per year for information for all
employees’ subject to controlled substance and alcohol testing under this part to determine whether information exists in the Clearinghouse
about those employees. A limited query will be performed after the driver grants consent. Individual drivers may give consent to conduct
limited queries that is effective for more than a year. The limited query will tell the employer whether there is information about the individual
driver in the Clearinghouse but will not release that information to the employer. If the limited query shows that information exists in the
Clearinghouse about the individual driver, the company and/or its C/TPA will conduct a full query within 24 hours. The driver must grant the
employer specific consent through the Clearinghouse to conduct the full query. If the employer fails to conduct, or the driver fails to give
consent for the full query within 24 hours, the employer must not allow the driver to continue performing SSF until the employer conducts the
full query and the results confirm that the driver’s Clearinghouse record contains no prohibitions.
Consequence of Violations found in the Clearinghouse - In the event the Clearinghouse indicates there is a D&A violation of the
prohibitions as established by Part 382 of the regulations, and the driver has not completed an SAP evaluation, referral, and
education/treatment process set forth in part 40, subpart O, of this title, the driver must be removed from/not to be allowed to perform SSFs
and will be subject to the consequences as outlined in this policy.

Alcohol and Controlled Substance Receipt of Addendum to Company D&A Testing Policy re: FMCSA D&A Testing
Clearinghouse

I certify that I have received and understand the D&A policy addendum explaining the requirements of 49 CFR Part 382 Subpart G in
regard to the responsibilities of my company to report any violations to and query the FMCSA D&A Testing Clearinghouse as of
January 6, 2020.
Driver’s Name (printed): ______________________________________________________________________________________
Driver’s Signature: _________________________________________________ Date: ____________________________________
 PREVIOUS PRE-EMPLOYMENT EMPLOYEE
ALCOHOL AND DRUG TEST STATEMENT

Sec. 40.25(j) As the employer, you must also ask the employee whether he or she has tested positive, or refused to
test, on any pre-employment drug or alcohol test administered by an employer to which the employee applied for,
but did not obtain, safety-sensitive transportation work covered by DOT agency drug and alcohol testing rules
during the past two years. If the employee admits that he or she had a positive test or a refusal to test, you must
not use the employee to perform safety-sensitive functions for you, until and unless the employee documents
successful completion of the return-to-duty process. (see Sec. 40.25(b)(5) and (e))

Prospective Employee Name: ID Number:

(print)

The prospective employee is required by Sec. 40.25(j) to respond to the following questions.

1) Have you tested positive, or refused to test, on any pre-employment drug or alcohol test
administered by an employer to which you applied for, but did not obtain, safety-
sensitive transportation work covered by DOT agency drug and alcohol testing rules
during the past two years?

Check one: □ Yes □ No

2) If you answered yes, can you provide/obtain proof that you’ve successfully completed the
DOT return-to-duty requirements?

Check one: □ Yes □ No

I certify that the information provided on this document is true and correct.

Prospective Employee Signature: Date:

Witnessed By: Date:

(signature)

© Copyright 2003
Published by J. J. KELLER & ASSOCIATES, INC.
Neenah, WI 54957-0368 886-F 6802
1-800-327-6868 • www.jjkeller.com (Rev. 7/03)
 Reset Form

ANNUAL REVIEW OF DRIVING RECORD

NAME OF DRIVER:

ID NUMBER:
Allen Distribution 1532 Commerce Avenue, Carlisle PA 17015
MOTOR CARRIER:
Name and Address

INSTRUCTIONS TO CARRIER: At least once every 12 months, obtain the motor vehicle record (MVR) of each driver,
covering at least the preceding 12 months, from each driver’s licensing authority where the driver held a commercial motor
vehicle operator’s license or permit during that time period.
Review the MVR in accordance with 49 CFR §391.25, as outlined below, and complete the Certificate of Review.
The purpose of the review is to determine whether the driver meets minimum requirements for safe driving or is
disqualified to drive a motor vehicle pursuant to §391.15 or (for CDL holders) §383.51. When reviewing the MVR, consider
any evidence that the driver has violated applicable provisions of the Federal Motor Carrier Safety Regulations or
Hazardous Materials Regulations. Also consider the driver’s accident record and any evidence that the driver has violated
laws governing the operation of motor vehicles. Motor carriers must give great weight to violations — such as speeding,
reckless driving, or operating while under the influence of alcohol or drugs — that indicate that the driver has exhibited a
disregard for public safety.

CERTIFICATE OF REVIEW
I hereby certify that I have reviewed the driving record of the above-named driver in accordance with
49 CFR §391.25 and find that the driver (check one):

❑ Meets minimum qualifications for safe driving

❑ Does not meet minimum qualifications for safe driving
❑ Is disqualified to drive a motor vehicle pursuant to §391.15 or §383.51

Notes/actions taken:

Reviewed by:
Signature Date

Printed Name Title

MAINTAIN THIS DOCUMENT IN THE DRIVER’S QUALIFICATION FILE FOR THREE YEARS FROM REVIEW DATE
(see 49 CFR §391.51)

Copyright 2022 J. J. Keller & Associates, Inc. • Neenah, WI • JJKeller.com • (800) 327-6868 • Printed in the USA 66630
 RECORD OF ROAD TEST
Driver's Name: Address:

License No.: State: Equipment Driven: Truck/Tractor: Trailer:

Checked From: To: Date:

For those items that apply, checkmark (✓) if driver's performance is satisfactory, mark with an X if driver's performance is unsatisfactory.
Explain unsatisfactory items under Remarks. Use not applicable (NA) for items that do not apply.
PART 1 – PRE-TRIP INSPECTION AND EMERGENCY D. STEERING
EQUIPMENT Controls steering wheel
Checks general condition approaching unit Good driving posture and good grip on wheel
Looks for leakage of coolants, fuel, lubricants E. LIGHTS
Checks under hood – oil, water, general condition Knows lighting regulations
of engine compartment, steering Uses proper headlight beam
Checks around unit – tires, lights, trailer hook up, Dim lights when meeting or following other traffic
Brake and light lines, body, doors, horn, windshield Adjusts speed to range of headlights
Wipers
Proper use of auxiliary lights
Tests brake action, tractor protection valve and
parking (hand) brake PART 4 – BACKING AND PARKING
A. BACKING
Checks horn, windshield wipers, mirrors, emergency Gets out and checks before backing
equipment, reflectors, flares, fuses tire chains (if
necessary), fire extinguisher Looks back as well as uses mirror
Checks instruments for normal readings Gets out and rechecks conditions on long back
Checks dashboard warning lights for proper functioning Avoids backing from blind side
Cleans windshield, window, mirrors, lights, reflectors Signals when backing
Reviews and signs previous report Controls speed and direction properly while backing
PART 2 – COUPLING AND UNCOUPLING B. PARKING (City)
Does not hit nearby vehicles or stationary objects
Lines up units
Parks proper distance from curb
Connects glad hands to trailer to apply trailer
brakes before coupling Sets parking brake, puts in gear, chocks wheels,
shuts off motor
Connects glad hands and light line properly
Checks traffic conditions and signals when
Couples without difficulty pulling out from parked position
Raises landing gear fully after coupling Parks in legal and safe location
Visually checks king pin assembly to be certain C. PARKING (Road)
of proper coupling Parks off pavement
Checks coupling by applying hand valve or tractor Avoids parking on soft shoulder
protection valve (trailer air supply valve) and gently
applying pressure by trying to pull away from trailer Uses emergency warning signals when required
Assure that surface will support trailer before Secures unit properly
uncoupling PART 5 - SLOWING AND STOPPING
PART 3 – PLACING VEHICLE IN MOTION AND USE OF Uses gears properly ascending
CONTROLS Gears down properly descending
A. ENGINE Stops and restarts without rolling back
Places transmission in neutral before starting engine
Tests brakes before descending grades
Starts engine without difficulty
Uses brakes properly on grades
Allows proper warm-up
Uses mirrors to check traffic to rear
Understands gauges on instrument panel
Signals following traffic
Maintains proper engine speed (rpm) while driving Avoids sudden stops
Does not abuse motor Stops smoothly without excessive fanning
B. CLUTCH AND TRANSMISSION Stops before crossing sidewalk when coming out of
Starts loaded unit smoothly driveway or alley
Uses clutch properly Stops clear of pedestrian crosswalks
Times gearshifts properly PART 6 - OPERATING IN TRAFFIC PASSING AND TURNING
Shifts gears smoothly A. TURNING
Uses proper gear sequence Signals intention to turn well in advance
C. BRAKES Gets into proper lane well in advance of turn
Knows proper use of tractor protection valve Checks traffic conditions and turns only when
Intersection is clear
Understands low air warning
Restricts traffic from passing on right when preparing
Tests service brakes
to complete right hand turn
Builds full air pressure before moving Completes turn promptly and safely and does not
impede other traffic
Copyright 2019 J. J. Keller & Associates, Inc., Neenah, WI • USA • 920-722-2848 FORM #3256 (6/19)
B. TRAFFIC SIGNS AND SIGNALS Goes ahead when given right-of-way by others
Approaches signal prepared to stop if necessary
Does not crowd other drivers or force way
Obeys traffic signal through traffic
Uses good judgment on yellow light Allows faster traffic to pass
Starts smoothly on green Keeps right and in own lane
Notices and heeds traffic signs Uses horn only when necessary
Obeys "Stop" signs Generally courteous and uses proper conduct
C. INTERSECTIONS PART 7 – MISCELLANEOUS
Adjusts speed to permit stopping if necessary A. GENERAL DRIVING ABILITY AND HABITS
Checks for cross traffic regardless of traffic controls Consistently alert and attentive
Yields right-of-way for safety Adjusts driving to meet changing conditions
D. GRADE CROSSINGS Performs routine functions without taking eyes
Adjusts speed to conditions from road
Makes safe stop, if required Checks instruments regularly while driving
Selects proper gear and does not shift gears Willing to take instructions and suggestions
while crossing Adequate self-confidence in driving
Knows and understands federal and state rules governing grade
Is not easily angered
crossing
E. PASSING Positive attitude
Passes with sufficient clear space ahead Good personal appearance, manner, cleanliness
Does not pass in unsafe location: hill. curve, Good physical stamina
Intersection B. HANDLING OF FREIGHT
Signals change of lanes Checks freight properly
Warns driver being passed Handles and loads freight properly
Pulls out and back with certainty Handles bills properly
Does not tailgate Breaks down load as required
Does not block traffic with slow pass C. RULES AND REGULATIONS
Allows enough room when returning to right lane Knowledge of company rules
Knowledge of regulations: federal, state, local
F. SPEED
Speed consistent with basic ability Knowledge of special truck routes
Adjusts speed properly to road, weather, D. USE OF SPECIAL EQUIPMENT (Specify):
traffic conditions, legal limits
Slows down for rough roads
Slows down in advance of curves. intersection, etc.
Maintains consistent speed
G. COURTESY AND SAFETY
Uses defensive driving techniques
Yields right-of-way for safety
REMARKS:

GENERAL PERFORMANCE: Satisfactory _____________________ Needs Training __________________ Unsatisfactory ________________

QUALIFED FOR: Truck __________________ Tractor-Semitrailer __________________ Other:

_____________________________________________________________
Signature of Examiner

CERTIFICATION OF ROAD TEST

Instructions to Carrier: If the road test is successfully completed, the person who gave it must complete the following certification in duplicate. The
original of the signed road test form and the original of the Certification of Road Test shall be retained in the driver qualification file of the person who
was examined, and duplicate copies provided to the person examined. Section 391.31 (e){f)(g)(1 )(2) of the Federal Motor Carrier Safety Regulations.
Driver’s Name: Type of Power Unit: Automatic Day Cab
Social Security No: Type of Trailer(s): 53' Dry Van
Operator’s or Chauffeur’s Lic. No.: State: If Passenger Carrier, Type of Bus:
This is to certify that the above-named driver was given a road test under my supervision on ____________________, 20 ____ consisting of
approximately _________ miles of driving. It is my considered opinion that this driver possesses sufficient driving skills to operate safely the type of
commercial motor vehicle listed above.
Signature of Examiner: Organization: Allen Distribution
Title: Address of Examiner (City & State): 1532 Commerce Avenue, Carlisle, PA 17015
 Driver Proficiency (Title 13 CCR, 1229)
And Authorized Vehicles (Title 13 CCR, 1234 (b))

___________________________________ ________________________________
Driver’s Name Commercial Driver’s License Number

has demonstrated to me ___________________________________________________________

Name and Title

That he/she can safely operate the below named vehicles/equipment:

__________ straight truck

__________ tractor and trailer combination

__________ doubles/triples

__________ tank vehicle

__________ vehicles less than 10,000 pounds GVWR

__________ vehicles less than 10,000 pounds to 26,000 pounds GVWR

__________ vehicles 26,001 pounds and more GVWR

__________ bus with air brakes ____________ passengers

__________ bus with hydraulic brakes ____________ passengers

__________ standard shift transmission

__________ automatic transmission only

__________ air brakes endorsement

__________ hazardous materials endorsement

__________ special equipment (specify) _____________________________________

CTA 1229 9/97

 Clinic Authorization Letter

DONOR INSTRUCTIONS: You must bring this Clinic Authorization Letter, Chain of Custody (COC) form, and valid picture
ID (e.g., driver’s license) with you to your approved clinic for required testing.

Company Name: Allen Distribution

Location (if applicable):

Name of Donor:
Employee ID:
Employee’s Driver License: State:

To Perform the Following: DOT Non-DOT

CLINIC NOTE – UTILIZE THE COC FORM PROVIDED BY DONOR

Test Drug and Alcohol when both are indicated.

Pre-Employment Drug
Reasonable Suspicion Drug Breath Alcohol
Post-Accident Drug Breath Alcohol
Return to Duty Drug Breath Alcohol
Follow Up Drug Breath Alcohol
Physical New Hire Re-Certification
Hair Testing
Other:

CLINIC NOTE – Follow instructions for completing the test as indicated on the back of COC form. Fax MRO copy
of the COC to the MRO fax number listed on the COC.

Email or fax employer’s copy of the COC form and alcohol test results to J. J. Keller:
Email: chains@jjkeller.com (preferred method)

Fax: 866-232-7153

Email or Fax BAT’s

Email: bats@jjkeller.com
Fax: 866-232-7153

Send Invoice To:

Email: clinicbilling@jjkeller.com (preferred method)
Fax: 920-967-7034
Mail: J. J. Keller & Associates, Inc.
P.O. Box 368
Neenah, WI 54957-0368

Invoice MUST include donor’s name, employee ID, date of service, type of service provided and the company name.
Sites are responsible to pay invoices for any DOT physical or Re-Cert.

For questions regarding this request, please contact:

J. J. Keller Clinical Services Department
800-218-0779

Copyright 2021 J. J. Keller & Associates, Inc., Neenah, WI • USA • 920-722-2848 FORM #2623 (8/21)
Confidential