City: Fairfield   State: AL   Phone (205) 333-4450

PART I – DOT DRUG AND ALCOHOL RELEASE
I authorize, per 49 CFR Part 40, the release of information from my DOT regulated drug and alcohol testing records by the carriers (company/school) listed
below for the sole purpose of transmitting such records to the above listed employer. I authorize release of the following information concerning DOT drug
and alcohol testing violations during the past three years: (i) alcohol tests with a result of 0.04 or higher; (ii) verified positive drug tests; (iii) refusals to be
tested (including verified, adulterated, or substituted results); (iv) other violations of DOT drug and alcohol testing regulations; (v) information obtained
from previous employers of a drug and alcohol rule violation(s); and (vi) documents, if any, of completion of a return-to-duty process following a rule
violation.
The information that I have authorized involves tests required by DOT. If any carrier (company/school) listed below furnishes information concerning
items (i) through (vi) above, I also authorize that carrier (company/school) to release and furnish the dates of my negative drug and/or alcohol tests and/or
tests with results below 0.04 during the three-year period and the name and phone number of any substance abuse professional who evaluated me during
the past three years.

FMCSA Notification of Driver Rights
In compliance with 49 CFR Part §391.23, you have certain rights regarding the performance history information that will be provided to
prospective employers. 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 prospective employers.
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-provided investigative information must submit a written request to prospective employers. 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. Prospective employers must
provide this information within five business days of receiving the written request. If prospective employers have not yet received the requested
information from the previous employer, then the five-day deadline will begin when the requested safety performance history information is
received. If you have not arranged to pick up or receive the requested records within 30 days of prospective employers making them available,
prospective employers may consider you to have waived your request to review the record.

PART II – CONSUMER REPORT DISCLOSURE AND RELEASE
In connection with your employment or application for employment (including contract for services), consumer reports may be requested from any consumer reporting agency. These reports may include the following types of information: names and dates of previous employers, reason for
termination of employment, work experience, accidents, and drug/alcohol use.
You have the right to make a request to the consumer reporting agency, upon proper identification, to the nature and substance of all information in its files on you at the time of your request, including the sources of information and the recipients of any reports on you that the consumer reporting agency has previously furnished within the two-year period preceding your request.

I hereby consent to your obtaining the above information from a consumer reporting agency. I hereby authorize procurement of consumer report(s). If hired or contracted, this authorization for Part II reports only 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.