Request for dot information safety-sensitive former employees

YES 
□
NO 
□
5.
Did the employee refuse to be tested ?
YES 
□
NO 
□
6.
Did the employee have other violations of DOT agency drug and alcohol testing regulations ?
YES 
□
NO 
□
7.
Did a previous employer report a drug and alcohol rule violation to you ?
YES 
□
NO 
□
8.
 
If you answered “YES” to any of the above items, did the employee complete the return to duty process ?
YES 
□
NO 
□
Note:
 If you answered “YES” to item 7, you must provide the previous employer’s report. If you answered “YES” to item 8, you 
must also transmit appropriate return to duty documentation (e.g., SAP report(s), follow-up testing record). 
Name of person providing information: _____________________________________________________________________ 
Title: ____________________________ Phone: _________________________________ Date: ___________________ 
Please note:
49 
CFR Part 40.25 and 49 CFR Part 382.405(h) mandates that previous employers must immediately provide 
information regarding any violations found.
DRIVER / APPLICANT CONSENT FOR RELEASE AUTHORIZATION 
(The person named below has applied to 
FLC TRANSPORT LLC
employment and has listed you as his/her past employer.) 
With my signature below, I am authorizing you to release any information regarding any DOT alcohol and/or controlled 
substance program and/or testing while I was under your employment, acting as your agent, under contract with you, or acting 
as your representative in any capacity during the preceding three years from the date listed below. A copy of this release form 
shall have the same force and effect as the original. This request is specific and to be released only to 
FLC TRANSPORT 
LLC
. Authorization of this release will expire once the requested information has been sent to 
FLC TRANSPORT LLC
. This 
authorization may not be used to provide information to any other person. I certify all former employer information 
provided by me is correct.