Driver Application form

Suggested format "release in information form : 49 part 40 drug and alcohol rest in section 1 " To be completed by the new employer , signed by the employee and transmitted by the previous employee

Employee printed or type name

Employee ssc or ID Number

I hereby authorise of information department of informarion and transport regulated drug and alcholol listing record sby my previous employee listed in section in 1.8 to the employe losted section This release in accordance with DOT regulation 95 cfr part 40 section 40.25 I Understand the recorf toin section 11.A by my previous employee is listed to be following DOT Listing regulationg items

(1) Alcihil rest with te result of 0.04 or higher

(2) Verified positive drugs Tests

(3) Refusuls to be tested

(4) Other Violations of Drug DOT Agency alchol testing agency

(5) Information obtained from previous employes of drug and alchol rule violations

(6) Documentation , if any , completion of return drug process following a eule violation

1.A

1.B

Section 11

To be completed by the previous employer teransmitted by the mail and fax To the new employer

11.A In the three years preior To tyhe date of the employee signature (in section ) for DOT regulating listing

If you answered yes to the above items you must provide the previous employee report, you must also transmit the approriate return to duty documentation (eg:SAP Reports (s) folow up losting result

11.B

Submit