Dot Consumer Report And Investigative Consumer Report Disclosure Form printable pdf download

DISCLOSURE AND AUTHORIZATION FOR RELEASE OF INFORMATION FOR EMPLOYMENT

PURPOSES - 49 CFR PART 391.23, DOT DRUG AND ALCOHOL TESTING

In accordance with DOT Regulations 49 CFR Part 391.23, I hereby authorize release of my DOT-regulated drug and alcohol testing

records by the DOT - regulated employer(s) listed below to Agency for the purpose of Agency transmitting such records to Agency

customer listed above. I understand that information/documents released pursuant to this Part II is limited to the following DOT -

regulated testing items, including pre-employment testing results, occurring during the previous three (3) years: (i) alcohol tests with a

result of 0.04 or higher; (ii) verified positive drug test; (iii) refusals to be tested (including adulterated and/or substituted tests); (iv) other

violations of DOT drug and alcohol testing regulations (i.e. violations of 49 CFR 382 subpart B); (v) information obtained from previous

employers of a drug and alcohol rule violation; and (vi) any documentation of completion of the return -to-duty process following a rule

violation.

If any company listed below furnishes Agency with information concerning items (i) through (vi) above, I also authorize such company

to furnish the following information to Agency, if applicable: (i) dates of my negative drug and/or alcohol tests and/or tests with results

below 0.04 during the previous three (3) years; and (ii) the name and phone number of any substance abuse professional who evaluated

me during the previous three (3) years.

List all DOT - regulated employers you have applied with and/or worked for in a safety - sensitive function during the previous three

(3) years. If necessary, attach additional pages, including the date, your name, social security number and signature.

Previous DOT- Regulated Employer

City

State

Telephone Number

_____________________________

______________

____________

(_______) ________ - _______________

_____________________________

______________

____________

(_______) ________ - _______________

_____________________________

______________

____________

(_______) ________ - _______________

_____________________________

______________

____________

(_______) ________ - _______________

_____________________________

______________

____________

(_______) ________ - _______________

By signing below, I certify that: (i) all information provided herein is complete and accurate; (ii) I have read and fully understand this

Part II disclosure and authorization for release; (iii) prior to signing I was given an opportunity to ask questions and to have those

questions answered to my satisfaction; (iv) I execute this authorization voluntarily and with the knowledge that the information obtained

pursuant to this authorization could affect my eligibility for employment, promotion, retention or other lawful purpose; (v) I understand I

may review this document with legal counsel prior to signing; and (vi) facsimile or photographic copies of this authorization are as valid

as an original.

Print Applicant Name: __________________________________

Date of Birth:_______________________________

Social Security #:____________________________

Applicant Signature:____________________________________

Date:______________________________________

CDL # ____________________ State:_____________________

H:\FCRA FORMS\CONSUMER REPORT AND INVETIGATIVE CONSUMER REPORT DISCLOSURE - DOT.doc

Dot Consumer Report And Investigative Consumer Report Disclosure Form

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