Release/ Authorization To Obtain Information

Requesting Employer Company Name: Waymore Transportation Inc., 8201 Hickory St N.E., Fridley, MN 55432,763-786-9076, Fax #763-786-7669

PART 1- 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: (a) alcohol tests with a result of 0.04 or higher; lb) verified positive drug tests; (c) refusals to be tested (including verified adulterated or substituted results);(d) other violations of DOT drug and alcohol testing regulations; (e) information obtained from previous employers of a drug and alcohol rule violation(s); and (d) 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 (a) through (d) 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.

TERMS OF ACCEPTANCE & SIGNATURE
I have completed this application, and that all entries on the application and information on the application are true and complete to the best of my knowledge. I authorize Waymore Transportation Inc., safety department, to make such investigations and inquires of/to my personal, employment, DOT regulated records, including information related to accidents, drug & alcohol testing, financial or medical history and other related matters as may be necessary to arriving at an employment or contractor employment decision. (Generally, inquires regarding medical history will be made only if and after a conditional offer of employment or contractor employment has been extended.) I hereby release former and current employers, schools, health care providers and other persons from all liability in responding to inquiries and releasing information in connection with this application. In the event of employment or contractor employment, I understand that false or misleading information given in this application or interview(s) may result in discharge. I also understand that I am required to abide by all rules and regulations of Waymore Transportation Inc.
I have completed this application, and that all entries on the application and information on the application are true and complete to the best of my knowledge. I authorize Waymore Transportation Inc., safety department, to make such investigations and inquires of/to my personal, employment, DOT regulated records, including information related to accidents, drug & alcohol testing, financial or medical history and other related matters as may be necessary to arriving at an employment or contractor employment decision. (Generally, inquires regarding medical history will be made only if and after a conditional offer of employment or contractor employment has been extended.) I hereby release former and current employers, schools, health care providers and other persons from all liability in responding to inquiries and releasing information in connection with this application. In the event of employment or contractor employment, I understand that false or misleading information given in this application or interview(s) may result in discharge. I also understand that I am required to abide by all rules and regulations of Waymore Transportation Inc.
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Please enter your First and Last Name
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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. a) YOU have the right to review information provided by previous employers. b) 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. c) 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. Also, 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 a"anged 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.