FSSolutions

100 Highpoint Drive, Suite 102
Chalfont, PA 18914
www.firstsourcesolutions.com

800.732.3784
215.396.5609
info@fssolutions.com

Form DQF04

CONSENT FOR RELEASE OF DRUG AND ALCOHOL TESTING INFORMATION AND TREATMENT RECORDS AND SAFETY PERFORMANCE HISTORY

APPLICANT: IF YOU ARE CURRENTLY OR WERE EMPLOYED BY A DOT REGULATED EMPLOYER DURING THE LAST THREE YEARS AND PERFORMED A SAFETY SENSITIVE FUNCTION FOR THAT EMPLOYER, PLEASE PROVIDE THE NAME OF THAT EMPLOYER, A COMPLETE MAILING ADDRESS, PHONE AND FAX NUMBER STARTING WITH THE AREA CODE. START WITH THE MOST RECENT EMPLOYER FIRST.

I authorize my above listed previous employers to disclose to FS Solutions or its designated agents information pertaining to my safety performance history with Department of Transportation regulated employers during the preceding three years. This will include any verified positive drug test result, any alcohol test result of .04 or above, any refusal to test (including verified adulterated or substituted drug test results), any other violation of Department of Transportation (DOT) agency drug and alcohol testing regulations and any records of evaluation and treatment, to include completion of DOT return to duty requirements, resulting from such violations or tests, conducted on me in accordance with 49 CFR Part 391, section 391.23(e), This will also include accident data as described in 49 CFR Part 391, section 391.23(d). I further authorize Background Check to disclose this information to the prospective employer listed below and agree to hold harmless any previous employers listed above, Background Check, its directors, employees, agents, or volunteers for any damage, loss of employment, or any negative outcome that may result from such disclosure. I understand that the prospective employer listed below is required to obtain this information in accordance with Federal regulations, specifically 49 CFR Part 391, section 391.23. This consent is subject to revocation at any time, however, such revocation does not apply to disclosures made prior to notice. This authorization expires without express revocation sixty (60) days from the date that appears below. I understand that I have the right to inspect and copy any written information disclosed.

FS Solutions Confidential ©2017

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110 E Folsom Blvd
Pocola, OK 74902

(918) 436-6030

(918) 436-6067

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