Please Return By FAX to (319) 626-3352
Heartland Express901 N Kansas Ave.North Liberty, IA 52317Ph:
(319) 626-3395FAX: (319) 626-3352
Applicant Name:
I hereby authorize you to release to Heartland Express, Inc. of
Iowa any and all information regarding my services, character, and
conduct while inyour employment, and you are released from any
liability, which may result from giving such information. In order
to enable Heartland Express, Inc.of Iowa to comply with the
requirements of 49 C.F.R. 391.23, I have listed below all of the
companies for which I have worked as a driver (safetysensative
funtion) during the past three (3) years. I authorize the release
of information they are required to maintain by 49 C.F.R. subpart B
part 382or 49 C.F.R. part 40 positive controlled substance test
results, and refusals to be tested within the three (3) years
preceding the date of this application.I hereby authorized and
direct my prior employers to release such information to Heartland
Express, Inc. of Iowa in personal interviews, telephoneinterviews,
letters, or any other material that insures confidentiality. I
hereby authorize Heartland Express, Inc. of Iowa to release such
information toany of its personnel whose duties require them to
assess this application or to make any recommendations or decisions
with respect to it.
Social Security Number:
Previous Employment Release
HireRight Release (Formerly known as DAC & USIS)
(______) (______)
(______) (______)
(______) (______)
(______) (______)
(______) (______)
(______) (______)
My initials by EACH of the following companies allows Heartland
to get the info. stated above.initial
each hereinitial
each here
Company 1
Company 3
Company 5
Company 7
Company 9
Company 11
Company 8
Company 6
Company 4
Company 2
Company 10
Company 12
In connection with my application for employment (including
contract for services) with Heartland Express, Inc., I understand
that a consumer reportwhich may contain public record information
is being requested from , HireRight, Tulsa, Oklahoma. This report
may include the following types ofinformation: names of previous
employers, dates of employment, reason for termination of
employment, work experience, accidents, etc. I furtherunderstand
that this report may contain public record information concerning
my driving record, workers' compensation claims, credit,
bankruptcyproceedings, criminal records, etc. from federal, state,
and other agencies which maintain such records; as well as
information from HireRightconcerning (1) previous driving record
requests made by others from such state agencies, (2)
state-provided driving record, (3) claims involving me inthe files
of insurance companies.
Release of Information From Previous Employer/Carrier
Date:
Applicant Signature:
I have the right to make a request to HireRight, upon proper
identification, to request the nature and substance of all
information in its files on me atthe time of my request, including
the sources of information, and the recipients of any reports on me
which HireRight has previously furnished withinthe three year
period preceding my request. HireRight can be contacted by mail at
PO Box 33181, Tulsa, OK 74153, or by phone at (800) 381-0645.I
hereby consent to your obtaining the above information from
HireRight and I agree that such information which HireRight has or
obtains regardingmy employment history with you, if I am hired,
will be supplied by HireRight to other companies which subscribe to
HireRight services.
I AUTHORIZE, WITHOUT RESERVATION, ANY PARTY OR AGENCY CONTACTED
BY USIS TO FURNISH THE ABOVE MENTIONEDINFORMATION.
Date:
Please Return By FAX to (319) 626-3352
Heartland Express
901 N Kansas Ave.
North Liberty, IA 52317
Ph: (319) 626-3395
FAX: (319) 626-3352
Applicant Name:
I hereby authorize you to release to Heartland Express, Inc. of
Iowa any and all information regarding my services, character, and
conduct while in your employment, and you are released from any
liability, which may result from giving such information. In
order to enable Heartland Express, Inc. of Iowa to comply with the
requirements of 49 C.F.R. 391.23, I have listed below all of the
companies for which I have worked as a driver (safety sensative
funtion) during the past three (3) years. I authorize the release
of information they are required to maintain by 49 C.F.R. subpart B
part 382 or 49 C.F.R. part 40 positive controlled substance test
results, and refusals to be tested within the three (3) years
preceding the date of this application. I hereby authorized
and direct my prior employers to release such information to
Heartland Express, Inc. of Iowa in personal interviews, telephone
interviews, letters, or any other material that insures
confidentiality. I hereby authorize Heartland Express, Inc.
of Iowa to release such information to any of its personnel whose
duties require them to assess this application or to make any
recommendations or decisions with respect to it.
Social Security Number:
Previous Employment Release
HireRight Release (Formerly known as DAC & USIS)
(______)
(______)
(______)
(______)
(______)
(______)
(______)
(______)
(______)
(______)
(______)
(______)
My initials by EACH of the following companies allows
Heartland to get the info. stated above.
initial
each here
initial
each here
Company 1
Company 3
Company 5
Company 7
Company 9
Company 11
Company 8
Company 6
Company 4
Company 2
Company 10
Company 12
In connection with my application for employment (including
contract for services) with Heartland Express, Inc., I understand
that a consumer report which may contain public record information
is being requested from , HireRight, Tulsa, Oklahoma. This
report may include the following types of information: names
of previous employers, dates of employment, reason for termination
of employment, work experience, accidents, etc. I further
understand that this report may contain public record information
concerning my driving record, workers' compensation claims, credit,
bankruptcy proceedings, criminal records, etc. from federal, state,
and other agencies which maintain such records; as well as
information from HireRight concerning (1) previous driving record
requests made by others from such state agencies, (2)
state-provided driving record, (3) claims involving me in the files
of insurance companies.
Release of Information From Previous Employer/Carrier
Date:
Applicant Signature:
I have the right to make a request to HireRight, upon proper
identification, to request the nature and substance of all
information in its files on me at the time of my request, including
the sources of information, and the recipients of any reports on me
which HireRight has previously furnished within the three year
period preceding my request. HireRight can be contacted
by mail at PO Box 33181, Tulsa, OK 74153, or by phone at (800)
381-0645. I hereby consent to your obtaining the above
information from HireRight and I agree that such information which
HireRight has or obtains regarding my employment history with
you, if I am hired, will be supplied by HireRight to other
companies which subscribe to HireRight services.
I AUTHORIZE, WITHOUT RESERVATION, ANY PARTY OR AGENCY CONTACTED
BY USIS TO FURNISH THE ABOVE MENTIONED INFORMATION.
Date:
HAEIREF
Fred Walters
Normal.dot
Fred Walters
11
Microsoft Word 10.0
7/26/2006 4:19:00 PM
4/28/2006 8:48:00 AM
7/26/2006 4:21:00 PM
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Heartland Express
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