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Step 2:
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or Spouse Works

First Name

Last Name

Employee No.

Home Address.

Address (line 2)

City

State

Zip Code

Home Phone

Cell phone

Email

Date of Birth

First Name

Last Name

Relationship

Home Phone

Cell Phone

Work Phone

Email

Primary Physician

Medical Facility

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Other information

l understand that as a condition of hire with the above named "Company", that I must consent to the release of all DOT mandated drug and alcohol information from all of the employers for which I worked in a DOT safety-sensitive position, or for which I took a DOT pre-employment drug test, during the previous two (2) years as required by DOT Part 40.25, (or three (3) years as required by Part 391.23 for any driver of a commercial motor vehicle).

I hereby authorize the following previous employer/ company to furnish the DOT information requested in section 2 below.

(Complete additional form for each previous DOT employer)

Certification: I have read and fully understand this authorization to release my previous drug and alcohol test information, identified by the questions below. to the Company listed above. l hereby acknowledge that failure to provide accurate information in response to this request for release of information could negatively affect my employment offer or subject me to disciplinary action up to and including termination if later discovered alter my employment with the Company begins.

Release of Previous Employer’s DOT Drug/Alcohol Testing Results

SECTION 2: TO BE COMPLETED BY PREVIOUS EMPLOYER

In accordance with DOT regulations, the Company, named above, is required to obtain ‐- and as a Previous Employer, you are required to release – DOT drug and alcohol information, listed below, concerning the Applicant/Employee, named above. This information request covers any period of employment of the Applicant/Employee by you going back 2 years (3 years for CMV drivers), from the date of this request. Please complete the following:

‘A reproduction of this authorization shall be deemed as effective and valid as an original. Rev. 2012

EMPLOYMENT BACKGROUND CHECK DISCLOSURE AND AUTHORIZATION DISCLOSURE

Drug Screen Compliance & Clinical Laboratory (“Company”) may obtain information about you from ClearStar Logistics, Inc., PO Box 1003, Cumming, GA 30028, 877-796-2559, or another third-party consumer reporting agency, for employment purposes, including without limitation, for the purpose of evaluating you for employment, promotion, reassignment and retention as an employee, at any time prior to or during your employment, if applicable, and without giving you any further notice. Thus, you may be the subject of a background check, also known as a “consumer report” and/or an “investigative consumer report,” which may include information about your character, general reputation, personal characteristics, and/or mode of living. These reports may contain, without limitation, all or some of the following types of information about you: credit history, social security number verification, address and alias history, personal references, professional references, employment history, education history, licenses, certifications, motor vehicle records, driving records, criminal history, and civil court record history. Credit history will only be requested where such information is substantially related to the duties and responsibilities of the applied-for position. You the right to know whether a consumer report has been obtained about you; and you have the right to request a copy of any report obtained by Company, a copy of “A Summary of Your Rights Under the FCRA,” and a complete and accurate written disclosure of the nature and scope of any investigative consumer report obtained by Company. An investigative consumer report is information on an individual’s character, general reputation, personal characteristics, or mode of living is obtained through a personal interview with an information source. The nature and scope of the most common form of investigative consumer report obtained for employment purposes is an interview with a reference, employer, coworker, supervisor, or customer.

New York and Maine residents only: You have the right to inspect and receive a copy of any investigative consumer report requested by Company by contacting the consumer reporting agency identified above directly. You may contact the Company to request the name, address and telephone number of the nearest unit of the consumer reporting agency designated to handle inquiries, which the Company shall provide with 5 days

New York and residents only: Upon request, you will be informed whether or not a consumer report was requested by Company, and if such report was requested, informed of the name and address of the consumer reporting agency that furnished the report. By signing below, you acknowledge receipt of Article 23-A of the New York Correction Law.

Oregon residents only: information describing you rights under federal and Oregon law regarding consumer identity theft protection, the storage and disposal of your credit information, and remedies available should you suspect or find that the Company has not maintained secured records will be provided upon request.
Washington State residents only: you have the right to request from the consumer reporting agency a written summary of your rights and remedies under the Washington Fair Credit Reporting Act.

Authorization

I acknowledge receipt of the Background Check disclosure and A Summary of Your Rights Under the FCRA, and certify that I have read and understand both documents. I hereby authorize Company to obtain background check information, including consumer reports and investigative consumer reports, about me from ClearStar Logistics, Inc., or another third-party consumer reporting agency, for employment purpose, including without limitation, for the purpose of evaluating you for employment, promotion, reassignment and retention as an employee, at any time prior to or during my employment, if applicable, and without giving me any further notice. To this end, I hereby authorize, without reservation, any credit bureau, creditor, employer, coworker, supervisor, customer, institution, school, collage, university, license or certificate grating entity, state department of motor vehicles, state department of revenue, court, governmental agency, law enforcement agency, information service bureau, insurance company, other record-keeping agency, person, administrator, organization, company, corporation, entity, and any other information sources, to furnish any and all background information requested by ClearStar Logistics, PO Box 1003, Cumming , GA 30028, 877-796-2559, www.clearstar.net, another third-party acting on behalf of Company, and/or Company itself, and regardless of whether the requested information was received from another source. I that a copy of this Authorization shall be as valid as the original.

New York residents only: By signing below, you acknowledge receipt of Article 23-A of the New York Correction Law.

Minnesota and Oklahoma resident only: please check this box if you would like to receive a copy of a consumer report if one is obtained by the Company.

California residents only: By signing below, you also acknowledge receipt of the NOTICE REGARDING BACKGROUND INVESTIGATION PURSUANT TO CALIFORNIA LAW. Please check this box if you would like to receive a copy of an investigative consumer report or consumer credit report at no charge if one is obtained by the Company whenever you have a right to receive such a copy under California law.