Last, First, M.I.
MM slash DD slash YYYY
Please list three professional references.
Disclaimer and Signature
I certify that my answers are true and complete to the best of my knowledge. If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release. You agree your electronic signature is the legal equivalent of your signature.
Drug/Alcohol Pre-Employment Disclosure Statement and Consent for Inquiry
- , in consideration for employment with Cal Coast Acidizing Service, hereby voluntarily disclose that I:
when seeking employment and/or while employed by a company regulated by the Department of Transportation.
Consent for Inquiry:
I authorize my current and/or previous DOT regulated employer(s) to confirm or deny the above statements, as the facts require.
Authorization to Release Information
In connection with my application for employment with Cal Coast Acidizing Service, Inc., I understand and agree that investigative inquiries are to be made on myself including, but not limited to, criminal convictions, motor vehicle history, educational transcripts, and other reports of any nature and type, including information in the public domain. These reports will include information as to my character, work, habits, performance, and experience together with reasons for termination of past employment.
I understand and agree that Cal Coast Acidizing Service, Inc. can and will be requesting information from various federal, state, and other agencies that maintain records concerning my past activities related to my driving, criminal, education, and other experiences.
I authorize without reservation all corporations, companies, persons, educational institutions, law enforcement agencies, and former employers to release information they may have about me, and release them from any liability and responsibility for doing so.
This authorization, in original and copy form, shall be valid for this and any future reports that may be requested.
I hereby authorize investigation of all statements made by me with no liability arising there from.
Employee Consent to Physical Exam
Cal Coast Acidizing Service, Inc. has adopted a policy requiring all employees to consent to physical examinations from time to time. The physical examination shall be conducted by a licensed physician as deemed necessary by the company. These examinations will be to determine the employee’s fitness and ability to work as well as to detect whether an employee is under the influence of alcohol and/or drugs while performing job duties. This policy is to protect all employees, the public, and the company. Each and every employee must consent to such examinations as a condition of continued employment with the company.
I hereby consent to taking any physical examination requested by CAL COAST ACIDIZING SERVICE, INC., at any time and give my consent for the examining physician, technologist, or laboratory to reveal to CAL COAST ACIDIZING SERVICE, INC. the results of the examination/test for its use in any manner it may wish.
Applicant Authorization to Release DOT Drug/Alcohol Test Results
I hereby authorize the release of information from my Department of Transportation regulated drug and alcohol testing records by my previous employers listed below:
To the requesting employer: Cal Coast Acidizing Service, Inc., P.O. Box 2050, Orcutt, CA 93457, (805) 934-2411.
This release is in accordance with DOT regulation 49 CFR Part 40, Section 40.25. I authorize release of the following information concerning DOT drug and alcohol testing violations including pre-employment tests during the past three years:
- Alcohol tests with a result of 0.04 or higher alcohol concentration;
- Verified positive drug tests;
- Refusals to be tested;
- Other violations of DOT agency drug and alcohol testing regulations;
- Documentation, if any, of completion of the return-to-duty process following a rule violation;
- Information obtained from previous employers of a drug and alcohol rule violation.
Applicant Certification: I have read and fully understand this authorization to release my previous drug and alcohol test information. In signing below, I certify that all of the information I have furnished on this form is true and complete, and that I have identified all of the employers for which I have worked in a DOT safety-sensitive position during the previous three years. I also understand that I am responsible for all costs associated with any pending Substance Abuse Professional assessment, recommendations, education, and treatment, including costs involving return-to-duty testing and follow-up testing yet to be completed.
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(Resume, DMV Printout, etc…)