PERSONNEL
403.6E03 - CONSENT FOR REQUEST OF INFORMATION
ATTENTION:
SUBSTANCE ABUSE PROGRAM COORDINATOR
COMPANY:
FAX:
DATE OF REQUEST
DRIVER:
SOCIAL SECURITY NUMBER:
1.
Dates of Employment:
From:
To:
From:
To:
From:
To:
2.
In the past two years, has the driver:
YES
NO
o
o
Tested positive for alcohol at a level of .04 or greater. If yes, list date(s) and type of test:
o
o
Tested positive for drugs. If yes, list date(s) and type of test below:
o
o
Refused either a drug or alcohol test. If yes, list date(s) and type of test below:
I certify that the above information is accurate.
Substance Abuse Program Coordinator
Date
I hereby authorize the company listed above to release my alcohol and drug screen information to the following company.
COMPANY:
WACO Community School District
ADDRESS:
706 N. Pearl, Wayland, Iowa 52654
FAX:
1-319-256-6213
Driver Signature
Date
By federal regulation this information must be on file in our office within two weeks of hire. Please fax or return this form to the address listed above at once. Please direct any questions to the above name and address.