Limited Power Of Attorney-To Obtain Pre-employment Screening Report(PSP)

Dear Federal Motor Carrier Safety Administration (FMCSA) regarding the

Pre-employment Screening Report or CSA-PSP Report: Pursuant to the enclosed
Limited Power of Attorney and accompanying documentation I am a commercial driver,
and I am requesting a copy of any and all records stored in your database(s).
I hereby appoint Danny Martinez as my designated Limited Power of Attorney. To communicate with the
FMCSA and its employees to request information include but not limited to Pre-Employment Screening
Program reports (PSP) or CSA2010-14 report, submit dispute(s) related to the accuracy and/or
completeness of Report information and/or submit rebuttal statement(s) on the data maintained by
FMCSA.
Due to the nature of Danny Martinezs services: providing professional drivers assistance to ensure
accurate and complete information is on record regarding safety information and the Carrier Safety
Services provided by Danny Martinez whom carrys out the dispute service (managed under Freedom of
Information Act), I understand that no refunds will be provided subsequent to the execution of this
document.
Further, I understand that:
a. Danny Martinez nor CarrierSafety.weebly.com is not a direct employer for drivers nor am I seeking
employment with Danny Martinez and/or CarrierSafety.weebly.com or any of its affiliates.
b. Danny Martinez is considered an Industry Service Provider defined as a person who offers provision
of records to commercial drivers who seek integrated pre-employment screening information about
themselves. This definition is per Danny Martinez and of his website listed as carriersafety.weebly.coms
agreement between NIC Technologies, LLC (the exclusive agent for online access to Federal Motor
Carrier Safety Administration Pre-Employment Screening Program records).

Please return my reports/data to my Limited Power of Attorney, Danny Martinez of

website: www.carriersafety.weebly.com P.O BOX 22827, NEWARK, NEW JERSEY 07101
Signature___________________________________
Full Name (print) __________________________________________
Address____________________________________
City _________________ State
Zip
Phone Number (
)_________________
Email address_______________________________
CDL License No. ____________________________
State of Issue:_______________________________
Expiration of License__________________________
DOB (mm/dd/yy)
(circle numbers below)
______________

Month of Birth
0
0

________________________

Day of Birth
0
0

Year of Birth
0
0

Copy CDL
HERE
Copy &
Display
Front
Side-Up
Only
Copy CDL
HERE

DRIVER: PLEASE Email THIS COMPLETED DOCUMENT ALONG WITH A COPY OF THE FRONT OF
YOUR CDL TO: CarrierSafety@gmail.com

Limited Power Of Attorney-To Obtain Pre-employment Screening Report(PSP)

Please return my reports/data to my Limited Power of Attorney, Danny Martinez of

website: www.carriersafety.weebly.com P.O BOX 22827, NEWARK, NEW JERSEY 07101

Requests/Comments/Additional Concerns:
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Signature___________________________________
Full Name (print) ___________________________________________
DRIVER: PLEASE Email THIS COMPLETED DOCUMENT ALONG WITH A COPY OF THE FRONT OF
YOUR CDL TO: CarrierSafety@gmail.com