Substance Abuse Release Form

Having made application for a position with

Your Name:
Your Email:

I request that their representative be informed as to my past substance abuse testing history. I hereby authorize the investigation of this past history to ascertain any and all information which may concern my past employment, as provided under DOT regulation (382.413) concerning previous alcohol and controlled substance testing records and any refusals to submit to such testing during the past three (3) years.

  • Alcohol test results of .04 or greater during the past three (3) years.
  • Positive controlled substance (drug) test results during the past three (3) years.
  • Refusal to be tested for either alcohol or controlled substances during the past three (3) years.
  • Has the applicant violated any other DOT mandated drug or alcohol regulation?
  • This applicant has not been screened for alcohol or controlled substances while employed by my company, or the date of the last test of this kind is greater than three (3) years ago.
  • Has the applicant tested positive or refused substance abuse screening with a previous employer?

You and your company are hereby released from any and all liability which may result from furnishing such information.


I, have been informed that my blood and/or urine is being screened for the abuse of alcohol and/or drugs.

I consent, of my own free will, to have test specimens taken before a witness, and the test results given to my employer.

Your Email:

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