PART I – DISCLOSURE AND AUTHORIZATION FOR RELEASE OF INFORMATION FOR EMPLOYMENT PURPOSES – 49 CFR PART 391.23, DOT DRUG AND ALCOHOL TESTING
In accordance with DOT Regulation 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 HireRight for the purpose of HireRight transmitting such
records to the HireRight customer listed above. I understand that information/documents released pursuant to this Part I 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 tests; (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 HireRight with information concerning items (i) through (vi) above, I al so authorize
such company to furnish the following information to HireRight, 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
By signing below, I certify that: (i) all information provided herein is complete and accurate; (ii) I have read and fully
understand this Part I disclosure and authorization for release as well as the attached FMCSA Notification of Driver Rights
and any applicable state law notices; (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 el gal counsel prior to signing; and v(i) facsimile or
photographic copies of this authorization are as valid as an original.