AUTHORIZATION RELEASE FOR ALCOHOL
AND / OR CONTROLLED SUBSTANCE TEST INFORMATION

Previous Contractor / Employer Employee

Company Name______________________________________________________________ Name __________________________

Company Address_______________________________________________________________ Social Security # ______________

In accordance with 49 CFR 382.405 (0 and 382.413 (b) of the Fleet Safety Compliance Manual, you are hereby authorized and requested to furnish any and all infor­ mation pertaining to my participation in an alcohol and controlled substance testing program under 49 CFR 382. I specifically authorize you to release any and all infor­ mation pertaining to my participation in an alcohol test resulting with a breath concentration of 0.04 or greater, controlled substance test with a positive result, and/or refusal to be tested within the two (2) years preceding the date of their request. I authorize and request you to release any and all information pertaining to my evalua­tion by a Substance Abuse Professional (SAP), and the identity of the Substance Abuse Professional (SAP).

X___________________________________ ____________________
Employee's Signature Date

Has the above mentioned person, within the last two years, preceding the date of this request:
•  Tested positive for a controlled substance? Yes / No
•  Tested with a breath concentration of 0.04 or greater? Yes / No
•  Refused to submit to an alcohol or controlled substance test? Yes / No
If YES to any of the above questions, please release the name, address, and phone number of the Substance Abuse Professional (SAP) for further reference.

DISCLOSURE AND RELEASE

In connection with my application for employment (including contract for services) with you, I understand that consumer reports which may contain public record information may be requested from DAC Services, Tulsa, Oklahoma. These reports may include the following types of information: names and dates of previous employers, reason for termination of employment, work experience, accidents, etc. I further understand that such reports may contain public record information concerning my driving record, workers' compensation claims, credit, bankruptcy proceedings, criminal records, etc., from federal, state and other agencies which maintain such records; as well as information from DAC concerning previous driving record requests made by others from such state agencies, and state provided driving records.
I AUTHORIZE, WITHOUT RESERVATION, ANY PARTY OR AGENCY CONTACTED BY DAC TO FURNISH THE ABOVE MENTIONED INFORMATION.
I have the right to make a request to DAC, upon proper identification, to request the nature and substance of all information in its files on me at the time of my request, including the sources of information; and the recipients of any reports on me which DAC has previously furnished within the two year period preceding my request. I hereby consent to your obtaining the above information from DAC, and I agree that such information which DAC has or obtains, and my employment history with you if I am hired, will be supplied by DAC to other companies which subscribe to DAC Services. I hereby authorize procurement of consumer report(s). If hired {or contracted), this authorization shall remain on file and shall serve as ongoing authorization for you to procure consumer reports at any time during my employment (or contract) period.

As part of its subscription agreement with DAC, Central Refrigerated Services, Inc. provides information to DAC and the applicant agrees that information regarding his employment with Central Refrigerated Services, Inc., including any accidents, citations and other similar information, can be provided to DAC.