I hereby authorize release of information from my Department of Transportation regulated drug and alcohol testing records by my previous employer, listed in Section I-B, to the employer listed in Section I-A. This release is in accordance with DOT Regulation 49 CFR Part 40, Section 40.25. I understand that information to be released in Section II-A by my previous employer, is limited to the following DOT-regulated testing items:

1. Alcohol tests with a result of 0.04 or higher;

2. Verified positive drug tests;

3. Refusals to be tested;

4. Other violations of DOT agency drug and alcohol testing regulations;

5. Information obtained from previous employers of a drug and alcohol rule violation;

6. Documentation, if any, of completion of the return-to-duty process following a rule violation.

II-A. In the two years prior to the date of the employee’s signature (in Section I), for DOT-regulated testing ~

1. Did the employee have alcohol tests with a result of 0.04 or higher? YES ____ NO ____

2. Did the employee have verified positive drug tests? YES ____ NO ____

3. Did the employee refuse to be tested? YES ____ NO ____

4. Did the employee have other violations of DOT agency drug and alcohol testing regulations? YES ____ NO ____

5. Did a previous employer report a drug and alcohol rule violation to you? YES ____ NO ____

6. If you answered “yes” to any of the above items, did the employee complete the return-to-duty process? N/A ____ YES ____ NO ____

   NOTE: If you answered “yes” to item 5, you must provide the previous employer’s report. If you answered “yes” to item 6, you must also transmit the appropriate return-to-duty documentation (e.g., SAP report(s), follow-up testing record).

   II-B.

   Name of person providing information in Section II-A: _______________________________________________

   Title: ___________________________________________

   Phone #: ________________________________________

   Date: ___________________________________________