Applicant Drug & Alcohol Release Form

I hereby authorize the release of information from my Department of Transportation regulated drug and alcohol testing records by my previous employers listed below:

Previous Company:

Phone:

Address, City, State, Zip

To the requesting employer / individual: ______________________________________________________

City:_______________ State :______ Phone:____________________
and/or its Background Screening agent I-NEX Solutions, Inc., Tampa, FL, (813) 963-0004

This release is in accordance with DOT regulation 49 CFR Part 40, Section 40.25. I authorize release of the

following information concerning DOT drug and alcohol testing violations including pre-employment tests during the past three years:

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

2. Verified positive drug tests;

3. Refusals to be tested;

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

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

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

Applicant Signature	Date
Printed Name	Social Security Number

** Incomplete forms will not be accepted **

In compliance with FMCSA regulation 391.23 part (i)(1) you have certain rights regarding the investigative information that will be provided to the prospective employer: i) You have the right to review information provided by previous employers; ii) You have the right to have errors in the information corrected by the previous employer and for that previous employer to re-send the corrected information to the prospective employer; iii) You have the right to have a rebuttal statement attached to the alleged erroneous information, if the previous employer and the driver cannot agree on the accuracy of the information. (2) Drivers who have previous DOT regulated employment history in the preceding three years and wish to review previous employer investigative information must submit a written request to the prospective employer. This may be done at any time, including when applying, or as late as 30 days after being employed or being notified of denial of employment. The prospective employer must provide this information within five business days of receiving the written request. If the prospective employer has not yet received the requested information from the previous employer, then the five-business day deadline will begin when the prospective employer receives the requested safety performance history information. If the driver has not arranged to pick up or receive the requested records within 30 days of the prospective employer making them available, the prospective employer may consider you to have waived your request to review the records.