DOT Release Form Name First Middle Last Social Security Number SignatureI hereby authorize the following employers to release and forward all information and records on my DOT alcohol and drug testing and vehicle accident records to HireRight, Inc. Date MM slash DD slash YYYY Current EmployerCurrent EmployerCurrent EmployerCurrent EmployerAddressPhoneDate Employed MM slash DD slash YYYY Rate of Pay Unit of pay%cpmhourlySelect a unit of payReason for Leaving May we contact? Yes No Former Employer 1Former Employer 1Company NameAddressPhoneStart Date MM slash DD slash YYYY End Date MM slash DD slash YYYY Rate of Pay Unit of pay%cpmhourlySelect a unit of payReason no longer employed Former Employer 2Former Employer 2Company NameAddressPhoneStart Date MM slash DD slash YYYY End Date MM slash DD slash YYYY Rate of Pay Unit of pay%cpmhourlySelect a unit of payReason no longer employed Former Employer 3Former Employer 3Company NameAddressPhoneStart Date MM slash DD slash YYYY End Date MM slash DD slash YYYY Rate of Pay Unit of pay%cpmhourlySelect a unit of payReason no longer employed Former Employer 4Former Employer 4Company NameAddressPhoneStart Date MM slash DD slash YYYY End Date MM slash DD slash YYYY Rate of Pay Unit of pay%cpmhourlySelect a unit of payReason no longer employed Former Employer 5Former Employer 5Company NameAddressPhoneStart Date MM slash DD slash YYYY End Date MM slash DD slash YYYY Rate of Pay Unit of pay%cpmhourlySelect a unit of payReason no longer employed