JASKO - Request for Correction of Erroneous Safety Performance History Information

FMCSA 49 C.F.R. 391.23(j)(1)–(j)(2) — Driver/Applicant Request

Rev. 2026-09-27

REQUEST FOR CORRECTION OF ERRONEOUS SAFETY PERFORMANCE HISTORY INFORMATION — 391.23

This request is made by the driver/applicant in compliance with Department of Transportation Regulations, §391.23, Investigations and Inquiries, paragraphs (j)(1) and (2).

SECTION 1: COMPLETED BY THE DRIVER/APPLICANT

I request correction of erroneous information in my safety performance history record be forwarded to the following prospective employer:

Explanation of desired correction (attach documents as necessary):

Driver: Retain copy 4 for your files. Submit copies 1, 2, and 3 to your previous employer.

SECTION 2: COMPLETED BY THE PREVIOUS EMPLOYER

Disposition of the requested information: Information was copied and forwarded to the prospective motor carrier employer — or the driver’s request was returned, indicating that the previous employer did not agree to correct the data.

SECTION 3: COMPLETED BY THE PROSPECTIVE MOTOR CARRIER EMPLOYER

The corrected information was received on (date), by the prospective employer, received by (signature), title.

JASKO Enterprises, Inc. — 1122 N. 189th Ave, Buckeye, AZ 85326

Your information

Previous employer (company name) * Employer street * Employer city * Employer state * Employer ZIP code * Driver/applicant full name * Last 4 of Social Security number * Your street * Your city * Your state * Your ZIP code * Telephone number * Forward correction to (prospective employer) * Attention Employer street * Employer city * Employer state * Employer ZIP code * Fax number Email address Explanation of desired correction * Date *

Signature

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