403.7E3 - Consent for Request of Information

ATTENTION:    SUBSTANCE ABUSE PROGRAM COORDINATOR

COMPANY:  ___________________________________________________________

FAX:  _________________________________

DATE OF REQUEST:  _______________________________________

DRIVER:  _____________________________________________________________

SOCIAL SECURITY NUMBER:  __________________________________________

1.  Dates of Employment:  From:  _____________________  To:  _____________________ 
                                           From:  _____________________  To:  _____________________ 
                                           From:  _____________________  To:  _____________________ 

2.  In the past two years, has the driver:

          YES         NO
                                            Tested positive for alcohol at a level of .04 or greater.  If yes, list date(s) and type of
           ___         ___        __________________________________________________________
                                       __________________________________________________________

                                            Tested positive for drugs.  If yes, list date(s) and type of test below:
           ___         ___        __________________________________________________________
                                       __________________________________________________________

                                       Refused either a drug or alcohol test.  If yes, list date(s) and type of test below:
           ___         ___        __________________________________________________________
                                       __________________________________________________________

I certify that the above information is accurate.

____________________________________     _____________________________
Substance Abuse Program Coordinator                                           Date

 

I hearby authorize the company listed above to release my alcohol and drug screen information to the following:

COMPANY:  ___________________________________________________________

ADDRESS:  ___________________________________________________________

FAX:  _________________________________

____________________________________     _____________________________
Driver Signature                                                                                             Date

 

By federal regulation this information must be on file in our office within two weeks of hire.  Please fax or return this form to the address listed above at once.  Please direct any questions to the above name and address.