Request/Consent Form For Information From Previous Employer(s) For Alcohol & Controlled Substances Testing Records

 

Requesting Motor Carrier:

 

Company:         Warren Transport, Inc.                          Phone No.:                    319-235-6299 or 800-832-0555

Address:           P.O. Box 420                                        Confidential Fax:           319-235-6555 or 800-281-9609

                        Waterloo, Iowa 50704                            Contact Person: ____________________________________

 

SECTION 1:  TO BE COMPLETED BY PROSPECTIVE COMMERCIAL MOTOR VEHICLE DRIVER

 

Name:_____________________________  Date of Birth___________________ Soc. Sec. No._____________________

 

                In accordance with Department of Transportation regulations, 382.405, 382.413, and 40.321 (b), I hereby authorize and request that Warren Transport, Inc. obtains the required information from each of my previous employers, as the term is used in the regulations, for the past three (3) years, and you are hereby authorized and requested to furnish to the above named person at Warren Transport, Inc., any and all information in your possession concerning my participation in a controlled substances and alcohol testing program under 49 CFR Part 382.  I specifically authorize you to release information on any alcohol tests with concentration result of 0.04 or greater, positive controlled substance test results and/or refusals to be tested within three years preceding the date of this request. 

                A photocopy or electronic facsimile of this release shall be as valid as the orginal.  This authorization shall be valid for one year from the date of signing hereof.

 

Signature:_______________________________________________________     Date:__________________________________________

 

Applicant:  DO NOT WRITE BELOW THIS LINE

 

SECTION 2:  TO BE COMPLETED BY PREVIOUS/CURRENT EMPLOYER

 

Company: ________________________________     Address:_______________________________________

 

Please make a Yes or No Selection for EACH question.
Has the driver ever refused a required drug or alcohol test?	Yes   	No   
Has the driver ever tested positive on a required controlled-substance test?	Yes   	No   
Has the driver ever tested at or above 0.04 on any required alcohol test?	Yes   	No   
Has the driver ever violated any other provisions of the DOT drug and alcohol testing regulations?	Yes   	No   
Have you received information from any previous employer that this individual violated DOT drug and alcohol regulations?	Yes   	No   

 

 

________________________________________________________                ____________________________________________________

Print Name of Authorized Company Representative                    Signature of Authorized Company Representative

 

Date:_______________________________________

 

SECTION 3:  TO BE COMPLETED BY PROSPECTIVE QUALIFYING MOTOR CARRIER

 

RELEASE OF INFORMATION Person interviewed from previous employer:	CONSENT FORM       Faxed . . .       Mailed . . .             to previous/current employer
Interviewed by:	INTERVIEW METHOD     Faxed     Mailed     Phone     Personal Interview
Date:
Date received back: