HireRight Form

HireRight Form

HireRight Customer:

Company Name: Phoenix Transportation SVS Llc
Company Contact Name:
Fax #: (502) 863-0029
HireRight Account Code: IZCNN

TRUCKING INDUSTRY:
DOT D/A Disclosure and Authorization
Send to Fax# (800) 257-8069

PART I - DISCLOSURE AND AUTHORIZATION FOR RELEASE OF INFORMATION FOR EMPLOYMENT PURPOSES - 49 CFR PART 391.23, DOT DRUG AND ALCOHOL TESTING

In accordance with DOT Regulation 49 CFR Part 391.23, I hereby authorize release of my DOT-regulated drug and alcohol testing records by the DOT-regulated employer(s) listed below to HireRight for the purpose of the HireRight transmitting such records to the HireRight customer listed above. I understand that this information/documents released pursuant to this Part I is limited to the following DOT-regulated testing items, including pre-employment testing results, occurring during the previous three (3) years: (i) alcohol tests wit ha result of 0.04 or higher; (ii) verified positive drug tests; (iii) refusals to be tested (including adulterated and/or substituted tests); (iv) other violations of DOT drug and alcohol testing regulations (i.e., violations of 49 CFR 382 Subpart B); (v) information obtained from previous employers of a drug and alcohol rule violation; and (vi) any documentation of completion of the return-to-duty process following a rule violation.

If any company listed below furnishes HireRight with information concerning items (i) through (vi) above, I also authorize such company to furnish the following information to HireRight, if applicable: (i) dates of my negative drug and/or alcohol tests and/or tests with results below 0.04 during the previous three (3) years; and (ii) the name and phone number of any substance abuse professional who evaluated me during the previous three (3) years.

List all DOT-regulated employers you have applied with and/or worked for in a safety-sensitive function during the previous three (3) years.
Previous DOT-Regulated Employer
City
State
Phone Number
- Add another DOT-regulated employer
Previous DOT-Regulated Employer
City
State
Phone Number
- Add another DOT-regulated employer
Previous DOT-Regulated Employer
City
State
Phone Number
- Add another DOT-regulated employer
Previous DOT-Regulated Employer
City
State
Phone Number
- Add another DOT-regulated employer
Previous DOT-Regulated Employer
City
State
Phone Number
- Add another DOT-regulated employer
Previous DOT-Regulated Employer
City
State
Phone Number
By signing below, I certify that: (i) all information provided herein is complete and accurate; (ii) I have read and fully understand this Part I disclosure and authorization for release as well as the attached FMCSA Notification of Driver Rights and any applicable state law notices; (iii) prior to signing I was given an opportunity to ask questions and to have those questions answered to my sanctification; (iv) I execute this authorization voluntarily and with the knowledge that the information obtained pursuant to this authorization could affect my eligibility for employment, promotion, retention or other lawful purpose; (v) I understand I may review this document with legal counsel prior to signing; and (vi) facsimile or photographic copies of this authorization are as valid as an original.
Full Name*
Social Security Number*
Date*
Signature*
PART II - CONSUMER REPORT AND INVESTIGATIVE CONSUMER REPORT DISCLOSURE (FOR EMPLOYMENT PURPOSES)

In connection with your employment or application for employment (including contract for services) and in accordance with applicable laws, HireRight may obtain or assemble consumer reports and/or investigative consumer reports (collectively, "Reports") which may include information about you related to: previous employment (including employers, dates of employment, salary information, reasons for termination, etc.), safety performance including accident history and inspection history, academic history, verification of references and other information supplied by applicant, professional credentials, drug/alcohol use in violation of law and/or company policy, driving record, workers' compensation claims, credit history, creditworthiness, credit capacity, bankruptcy filings, criminal history records, information about your character, general reputation, personal characteristics and mode of living (collectively, "Information"). Information may be obtained from government agencies, educational institutions, HireRight clients, personal references, personal interviews and other Information suppliers (collectively, "Suppliers").

Upon providing proper identification and complying with any applicable legal requirements, you have the right to request to nature and substance of all Information in HireRight's files pertaining to you at the time of your request, including but not limited to: (i) whether any Reports have been provided by HireRight to other parties; (ii) identification of any Suppliers utilized by HireRight in compiling such Reports; and (iii) identification of any recipients of Reports furnished by HireRight within the two (2) year period preceding your request. HireRight may be contacted by mail at P.O. Box 33181, Tulsa, Oklahoma, 74143 or by phone at 800-381-0645.
- Check box if you are applying for employment in California and/or you are a California resident and, in either case, you wish to receive a copy of your credit report or investigative consumer report if one is obtained or assembled by HireRight. Pursuant to the California Civil Code, you may view the file maintained on you by HireRight during normal business hours. You may also obtain a copy of this file by submitting proper identification and paying applicable costs for such file, if required by law, by contacting HireRight in person or by mail. HireRight is required to have personnel available to explain your file to you and must explain to you any coded information appearing in your file. If you appear in person, a person of your choice may accompany you, provided that this person furnishes proper identification.
- Check this box if you are applying for employment in Oklahoma and/or you are an Oklahoma resident, and in either case, you wish to receive a copy of your consumer report if one is obtained or assemble by HireRight.
- Check this box if you are applying for employment in Minnesota and/or you are an Minnesota resident and, in either case, you wish to receive a copy of your Consumer Report if one is obtained or assemble by HireRight.
PART II - AUTHORIZATION FOR RELEASE OF INFORMATION (FOR EMPLOYMENT PURPOSES)

I hereby authorize HireRight to receive information and disclose such Information to its customers for the purpose of making a determination as to my eligibility for employment, promotion, retention or other lawful purpose. If hired or contracted, I authorize HireRight and the HireRight customer name above ("Customer") to retain this document on file to act as ongoing authorization for the procurement of possession of Reports at any time during my employment or contract period. I full release HireRight and Suppliers from all claims of damages related to the investigation of my background and provision of Information as set forth in this disclosure and authorization. I agree that Information in HireRight's possession and my employment history with Customer if I am hired, may be supplied by HireRight to other HireRight customers for legally permissible purposes; provided, such information will not include the Drug and Alcohol information set forth in Part I Above, unless I have given a separate specific consent for HireRight to share such information.

By signing below, I certify that: (i) all information provided within is complete and accurate; (ii) I have read and fully understand this Part II disclosure and authorization for release as well as the attached FMCSA Notification of Driver Rights and any applicable state law notices; (iii) prior to signing I was given an opportunity to ask questions and to have those questions answered to my satisfaction; (iv) I execute this authorization voluntarily and with the knowledge that the information obtained pursuant to this authorization could affect my eligibility for employment, promotion, retention or other lawful purpose; (v) I understand I may review this document with legal counsel prior to signing; (vi) I authorize HireRight and any person or entity contacted by HireRight to furnish the above-mentioned Information; and (vii) facsimile or photographic copies of this authorization are as valid as the original.

NOTE - THIS AUTHORIZATION DOES NOT APPLY TO DRUG & ALCOHOL INFO. ADDRESSED IN PART I.
Full Name*
Social Security Number*
Date*
Signature*
11/15/2011
USIS Edition

DOT Drug/Alcohol Disclosure/Authorization
Trucking Industry - Employment Purposes

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