Please print and fill out ONLY the sections listed in YELLOW. Then fax back to 812-824-9939 OR scan and email to email@example.com. If you prefer we can email you a release form directly where you can apply your electronic signature. Let us know what works best for you!
Release of Information Form 49 C.F.R. Part 40 Drug and Alcohol Testing Inquiry to Past Employers/Lessees
I hereby authorize release of information from my Department of Transportation regulated drug and alcohol testing records by my previous employer(s). This release is in accordance with DOT Regulation 49 CFR Par 40, Section 40.25. I understand that information to be released by my previous employer is limited to the following DOT-regulated items:
1. Alcohol test with a result of .04 or higher.
POSITIVE drug tests.
3. Refusals to be tested.
4. Other violations of DOT agency drug and alcohol testing regulations.
5. Information obtained from previous employers of a drug and alcohol rule violation.
6. Documentation, if any, of completion of the return-to-duty process following a rule violation.
Furthermore: I hereby authorize this company to release all information concerning records of my activity including oral assessments of my job performance, ability, and fitness to each and every company (or their authorized agents) which may request such information in connection with my request for qualification with said information request to the authorized agent of this company.
Name of Applicant: Social Security Number: .
1. Employed from to as at wage or salary of per .
2. Did he/she drive a motor vehicle for you? Yes No Straight Truck Tractor/Trailer .
3. Was he/she a safe and efficient driver? Yes No If no, please explain: .
4. Reason for leaving your employ: Discharged Resignation Lay Off Other
5. Please advise history of past driving record if available for the past three years.
Operating at maximum efficiency with built-in dependability - that's standard equipment.