Clearinghouse Consent Form

I,

(Driver Name), hereby provide consent to

(“Company”), through its C/TPA HireRight, LLC, to conduct a limited query of the FMCSA Commercial Driver’s License Drug and Alcohol Clearinghouse (the “Clearinghouse”) to determine whether drug or alcohol violation information about me exists in the Clearinghouse. If Company hires me, Company may conduct unlimited additional limited queries of the Clearinghouse for the duration of my employment. I understand that if the limited query conducted by Company indicates that drug or alcohol violation information about me exists in the Clearinghouse, FMCSA will not disclose that information to Company without first obtaining additional specific consent from me. I further understand that if I refuse to provide consent for Company to conduct a limited query of the Clearinghouse, Company must prohibit me from performing safety-sensitive functions, including driving a commercial motor vehicle, as required by FMCSA’s drug and alcohol program regulations.