DOT Release Form

Name
I 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.
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Current Employer

Current Employer
Current Employer
Current Employer
Address
Phone
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May we contact?

Former Employer 1

Former Employer 1
Company Name
Address
Phone
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MM slash DD slash YYYY
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Former Employer 2

Former Employer 2
Company Name
Address
Phone
MM slash DD slash YYYY
MM slash DD slash YYYY
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Former Employer 3

Former Employer 3
Company Name
Address
Phone
MM slash DD slash YYYY
MM slash DD slash YYYY
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Former Employer 4

Former Employer 4
Company Name
Address
Phone
MM slash DD slash YYYY
MM slash DD slash YYYY
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Former Employer 5

Former Employer 5
Company Name
Address
Phone
MM slash DD slash YYYY
MM slash DD slash YYYY
Select a unit of pay