Mercer Transporation Company

Mercer Safety Summary

First Name:
Middle Name:
Last Name:
Address
City, State, Zip
Phone No.
Date of Birth
Soc. Sec. No.
Alternate means of contact
E-mail address
CDL No., State
# of tickets last 3 years
# of accidents last 3 years
Tractor Make & Year
Trailer Make & Year

I hereby authorize any person or firms to furnish any information concerning my personal and safety habits, ability and financial status, physical well being and medical history.

May we contact any or all of the motor carriers listed below: Yes No

Present employer
Address
City
State
Zip
Dates of Employment:	From (mo/yr) To (mo/yr)
Phone No.
Type of Trailer
Number of States
Reason for Leaving

Previous employer
Address
City
State
Zip
Dates of Employment:	From (mo/yr) To (mo/yr)
Phone No.
Type of Trailer
Number of States
Reason for Leaving

Previous employer
Address
City
State
Zip
Dates of Employment:	From (mo/yr) To (mo/yr)
Phone No.
Type of Trailer
Number of States
Reason for Leaving

Previous employer
Address
City
State
Zip
Dates of Employment:	From (mo/yr) To (mo/yr)
Phone No.
Type of Trailer
Number of States
Reason for Leaving

Additional Information

I hereby authorize any person or firms to furnish any information concerning my personal and safety habits, ability and financial status, physical well being and medical history. I hereby release such person or persons from any liability for damages on account of furnishing such information. Public Law 91-508 requires that we advise you that a routine inquiry may be made which will provide applicable information concerning character, general reputation, personal characteristics, health and mode of living. Upon written request, additional information as to the nature and scope of the report, if one is made, will be provided. I certify that this Part 391 Safety Summary was completed by me, and all entries on it and information in it are True and Complete to the best of my knowledge.

Yes, I understand terms and conditions, check here.

Following submission of the safety summary, please contact Mercer's recruiting department at 800-433-0904 to expedite the processing of this document and to answer any additional questions that may arise.

The Safety Summary may also be printed out and faxed to our recruiting department at 800-648-2929.