Dear Potential Employee:
Thank you for considering TruCore Energy, LLC. as a place of employment. We pride ourselves in being an outstanding Company in our industry. We are confident your decision to apply with us will prove to be a good one. Before completing the Application for Qualification, please read the enclosed documents carefully to ensure that you qualify for employment with TruCore Energy, LLC. By completing this Application for Qualification, you are agreeing to theconditions of employment listed in the application itself and in any attached forms.
APPLICATION FOR EMPLOYMENT AND QUALIFICATION: The Application for Employment and Qualification is the first step to joining TruCore Energy, LLC. Complete the form in legible printed format and sign where required. If a section does not apply, write in N/A.On the additional pages, only complete areas indicated by -> or X. Additional pages include a Request for Driver’s Safety Performance History/Information from DOT Regulated Previous Employer(s) (2 pages), Request to HireRight, Job Description for Company Representative, Controlled Substance and Alcohol Testing Information,Acknowledgement/Consent Form, and Driver’s Rights Pertaining to Release of Driver Information Under Regulation 391.23.
IMPORTANT! You must fully complete the ten-year work history (including both driving and non-driving positions as well as paid and unpaid positions). If there is a gap in employment, please be sure to document the gap using the “Declaration of Employment Status” form to explain why you were unemployed or what you were doing during that time. If more space is needed please use a separate sheet of paper. Please remember: dishonesty on any application is grounds for immediate disqualification and/or termination.
INTERVIEW: You will be required to interview with the TruCore Energy, LLC. HR Manager, David Shelton, for an initial phone interview.
SAFETY/INTAKE INTERVIEW: You will be required to meet with our Intake Coordinators and complete any certifications you may need along with providing necessary trucks information to get you on the road, safely.
ROAD TEST: You will be required to demonstrate your ability to operate Company equipment by taking a road test.
DRUG SCREEN: You will also be required to pass a DOT FMCSA drug test.
All new drivers will be required to complete a two-hour orientation prior to leaving the yard with a load. Orientation will cover; paperwork, policies, procedures, safe driving practices, log books, pay documents and other related material. All DRIVERS WILL BE REQUIRED TO BRING ALL REQUIRED PPE TO ORIENTATION FOR VERIFICATION.
Please realize that applicants are accepted for hire on a competitive basis. When positions are available, the most qualified applicants at the time are contacted. While we cannot always hire every good applicant at any given time, we do keep all applications on file for one year
JOB DESCRIPTION for COMPANY REPRESENTATIVE, TRUCK DRIVER
REPORTS TO: Fleet Manager/Dispatcher
DUTIES & RESPONSIBILITIES
KNOWLEDGE, SKILLS & ABILITIES
Drivers must have the ability to:
I have read and understand the above job description and certify that I meet all qualifications and all physical requirements for this position
APPLICATION FOR QUALIFICATIONAnswer all questions – Please print
Applying as a Driver Applying as a Owner/Operator
City, State, Zip Code
License No. and State of Issue
In case of emergency notify
Name of Owner/Operator:
How were you referred?
Social Security #
Date of Birth
Endorsements: Doubles Hazmat Tanker
Have you ever been known by any name other than the one on this application? Yes No
If yes, list name(s):
List all past addresses in which you have lived during the (3) preceding years (if more space is needed, use separate sheet)
List all driver licenses you have held during the past three (3) years (if more space is needed, use separate sheet)
List states operated in for last five years:
Are you legally eligible for employment in the United States? YesNo
Are you able to perform all functions of a truck driver (with or without accommodation)? YesNo
How many years of experience do you have operating a Class A vehicle?
Do you have recent Tanker Truck experience YesNo
Do you have recent experience with double trailers? YesNo
If the answer to any of the below questions is “yes”, briefly explain on a separate piece of paper. Include dates and circumstances.Answering yes to any of the below questions will not necessarily disqualify you from employment with TruCore Energy, LLC
Have you ever been denied a license, permit or privilege to operate a motor vehicle? YesNo
Has any license, permit or privilege ever been suspended or revoked? YesNo
Have you ever been disqualified from driving a motor vehicle under the DOT regulations? YesNo
Have you ever been convicted of driving under the influence of alcohol or drugs?. YesNo
Have you ever tested positive or refused a DOT regulated drug and/or alcohol test? YesNo
Have you ever been convicted of careless or reckless driving?. YesNo
Have you been convicted of any crime within the last seven years? YesNo
Have you ever been convicted of a felony? YesNo
Do you have a Transportation Worker Identification Card (TWIC) YesNo
Have you graduated from a truck driving school? Yesno
If yes: Name of School , Year
Show special courses or training that will help you as a driver:
Which safe driving awards do you hold and from whom?
10 YEAR EMPLOYMENT HISTORY – Page 1
PLEASE BE THOROUGH! INCOMPLETE APPLICATIONS SLOW THE HIRING PROCESS!
Current or Most Recent Employer
Dates of Employment (month/year)
From : To :
Former Employer #2
From : To :
Former Employer #3
From : To :
Former Employer #4
Address (Street or PO Box )
From : To :
IF NECESSARY, CONTINUE 10 YEAR HISTORY ON “10 YEAR EMPLOYMENT HISTORY – Page 2”
10 YEAR EMPLOYMENT HISTORY – Page 2
Former Employer #5
From : To :
Former Employer #6
Former Employer #7
Address (Street or PO Box )
From : To :
Former Employer #8
From : To :
ATTACH SEPARATE SHEET IF MORE SPACE IS NEEDED FOR 10 YEAR HISTORYDRIVING EXPERIENCE
ACCIDENT RECORD FOR THE PAST 5 YEARS(Include Personal and Commercial, DOT and Non-DOT incidents/accidents)
Attach sheet if more room is needed
TRAFFIC CONVICTIONS AND FORFEITURES FOR THE PAST 5 YEARS (Other than parking violations)
TO BE READ AND SIGNED BY APPLICANT
This certifies that this application, including all attachments, was completed by me, and that all entries on it and information in it are true and complete to the best of my knowledge.
I understand and agree that:
I further understand that this is an application for employment and that no employment contract is being offered I have read and understand the above.
DECLARATION OF EMPLOYMENT STATUS
(This form must be completed by applicant if there are periods of time that cannot be verified, for instance: unemployment, self-employment, traveling, retirement, etc.)
Under the Federal Motor Carrier Safety Regulations Section 391.23, TruCore Energy, LLC is required to verify employment background of all prospective drivers for the preceding three (3) years. You have indicated that you were employed or selfemployed during the time period shown below. This form is designed to enable you to account for those periods during your employment history which cannot be verified by any other means. In the section below, please fill in the dates and describe your activities during those times.
Dates: From (Month/Year) : To (Month/Year)
During the period specified I was engaged as follows:
I also confirm that during the above period, the statements I have checked below are true:
I was not employed in any capacity on a full or part time basis, paid or unpaid I was self-employed I did not collect unemployment during this period I was not convicted of a crime or felony involving a motor carrier or any aspect of the carrier industry. My license was not suspended, revoked, or cancelled during this time. I was not involved in a motor vehicle accident of any type
Dates: From (Month/Year) : To (Month/Year)
During the period specified I was engaged as follows:
During the period specified I was engaged as follows:
I understand that this document is considered part of my employment application, and as such, any material misrepresentation or deliberate omission of a fact on this form may be justification for refusal of, or if employed, termination from employment.
CONTROLLED SUBSTANCE AND ALCOHOL TESTING INFORMATIONACKNOWLEDGEMENT/CONSENT FORM
As a condition of employment with TruCore Energy, LLC, Commercial Motor Vehicle (CMV) Driver Applicants must submit to a pre-employment controlled substances test as required by the Federal Motor Carrier Safety Regulations (FMCSR) Section 382.301. A motor carrier must receive verified negative test results for the applicant driver for the applicant to be eligible for employment.
If you are hired, you will be subject to laws requiring additional controlled substances and alcohol testing under numerous situations including, but not limited to, the following:
A driver who tests positive for a controlled substance(s) and/or alcohol test (including pre-employment testing), will be immediately removed from a safety-sensitive position as required by Part 382 of the FMCSR. Federal law prohibits a driver returning to a safety-sensitive position for any motor carrier until and unless the driver completes the Substance Abuse Professionals (SAP) evaluation, referral and educational/treatment process, as described in FMCSR Part 40, Subpart O.
Should you need the services of a Substance Abuse Professional (SAP), please contact your general manager or the Human Resource Department for a current list of SAP’s.
All controlled substances and alcohol testing will be conducted in accordance with Parts 40 and 382 of the FMCSR.
I , ,have read the above controlled substance and alcohol testing requirements and understand them.
3139 CR 205 N, Henderson, Texas 75652Phone: (903)722-9123 Fax: (903)392-8291
Motor carriers have the responsibility to make the following investigations and inquiries with respect to each driver employed, other than a person who has been a regularly employed driver of the motor carrier for a continuous period which began before January 1, 1971.
Drivers have the following rights:
Drivers who wish to review previous employer-provided investigative information must submit a written request to the prospective employer when applying or as late as 30 days after employed or being notified of denial of employment. The prospective employer must provide this information to the applicant within five business days of receiving the written request. If the driver has not arranged to pick up or receive the requested records within 30 days of the prospective employer making them available, the prospective motor carrier may consider the driver to have waived his/her request to review records.
Drivers wishing to request correction of erroneous information in records must send the request for the correction to the previous employer that provided the records. After October 29, 2004, the previous employer must either correct and forward the information to the prospective motor carrier employer or notify the driver within 15 days of receiving the driver’s request to correct the data that it does not agree to correct the data. Drivers wishing to rebut information in records must send the rebuttal to the previous employer with instruction to include the rebuttal in the driver’s Safety Performance History.
I acknowledge that I have read and understand the contents of this document.
Request for Driver’s Safety Performance HistoryInformation from DOT Regulated Previous Employer(s)
The person named below has applied for employment as a TRUCK DRIVER and states that he/she was employed by you as a from to . The applicant has waived any claim of liability against your company for information submitted in response to this inquiry.
►NAME OF APPLICANT
►SOCIAL SECURITY #
SECTION 1: WORK HISTORY (TO BE COMPLETED BY PREVIOUS EMPLOYER)
1. Is employment record with your company as stated above?
2. If employed as a driver, what type of equipment did he/she operate?
Type of trailer(s) pulled:
3. Was this driver issued a Longer Combination Vehicle (LCV) certificate (§380 of the FMCSRs) by your company?
If yes, please attach copy of LCV Certificate.
4. Was this driver a:
5. General area traveled:
6. Commodities transported:
7. While under your employment was he/she convicted of any traffic violations? .
If yes, list all, including date and type:
8. While under your employment was his/her license(s) suspended, revoked or denied?
If yes, please explain:
9. Reason for leaving your employment:
Details of discharge:
10. Would you re-employ this person:
11. Additional comments?
SECTION 2: ACCIDENT INFORMATION (TO BE COMPLETED BY PREVIOUS EMPLOYER)
Please provide the following information as required by 391.23(d)(1)(2) on any accidents, as defined by 390.5 and/or from your Accident Register (FMCSR 381.15) which the above-named driver/applicant was involved within the past three years while in your employment. Previous employers may include additional detailed information on minor accidents/incidents at their discretion. If there were no accidents please check here
NON-DOT INCIDENTS: Carriers may provide information about non-DOT incidents
EMPLOYMENT VERIFICATIONNon-DOT EmployerAUTHORIZATION TO RELEASE INFORMATION
I, , hereby authorize you to release all records of employment, including assessments of my job performance, ability and fitness, including dates and results of any and allalcohol or drug screens. I hereby release the above named company, and its employees, officers, directors, and agents from any and all liability of any type as a result of providing information to the above-mentioned person and/or company.
►Print Applicant Name:
►Social Security No:
To be completed by previous employer:
Dates of Employment: From: To:
Please briefly describe the duties this person performed for your organization:
Work performance? Exceptional Satisfactory Unsatisfactory
Reason for leaving your employ? Discharged Resigned Layoff/RIF
Would your re-employ this person? YesNo
Previous Employer to complete:
PART I – DOT DRUG AND ALCOHOL RELEASE
I authorize, per 49 CFR Part 391.23, the release of information from my DOT regulated drug and alcohol testing records by the carriers (company/school) listed below to DATCS for the sole purpose of transmitting such records to the above listed employer. I authorize release of the following information concerning DOT drug and alcohol testing violations including pre-employment tests during the past three years; (i) alcohol tests with a result of 0.04 or higher; (ii) verified positive drug tests; (iii) refusals to be tested (including verified adulterated or substituted results); (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(s) and (vi) documents, if any, of completion of a return-to-duty process following a rule violation.
The information that I have authorized DATCS to review involves tests required by DOT. If any carrier (company/school) listed below furnishes DATCS with information concerning items (i) through (vi) above, I also authorize that carrier (company/school) to release and furnish the dates of my negative drug and /or alcohol tests and/or tests with results below 0.04 during the three year period and the name and phone number of any substance abuse professional who evaluated me during the past three years.
►Print Applicant Name:
►Social Security Number:
FMCSA Notification of Driver Rights
In compliance with 49 CFR Part 391.23, you have certain rights regarding the performance history information that will be provided to prospective employers. I) You have the right to review information provided by previous employers. II) You have the right to have errors in the information corrected by the previous employer and for that previous employer to re-send the corrected information to prospective employers. III) You have the right to have a rebuttal statement attached to the alleged erroneous information, if the previous employer and the driver cannot agree on the accuracy of the information. (2) Drivers who have previous DOT regulated employment history in the preceding three years and wish to review previous employer-provided investigative information must submit a written request to prospective employers. This may be done at any time including when applying or as late as 30 days after being employed or being notified of denial of employment. Prospective employers must provide this information within five business days of receiving the written request. If prospective employers have not yet received the requested information from the previous employer, then the five-day deadline will begin when the requested safety performance history information is received. If you have not arranged to pick up or receive the requested records within 30 days of prospective employers making them available, prospective employer may consider you to have waived your request to review the record.
PART II – CONSUMER REPORT DISCLOSURE AND RELEASE
In connection with your employment or application for employment (including contract for services), consumer reports may be requested from HireRight . These reports may include the following types of information: names and dates of previous employers, reason for termination of employment, work experience, accidents, academic history, professional credentials, and drugs/alcohol use. Such reports may contain public record information concerning your driving record, workers’ compensation claims, credit, bankruptcy proceedings, criminal records, etc., from federal, state and other agencies which maintain such records; as well as information from HireRight concerning previous driving record requests made by others from such state agencies and state provided driving records.
You have the right to make a request to HireRight, upon proper identification, to request the nature and substance of all information in its files on you at the time of your request, including the sources of information and the recipients of any reports on you that HireRight has previously furnished within the three-year period preceding you request. HireRight may be contacted by mail at P.O Box 33181, Tulsa, Oklahoma, 74153, or by phone at (800) 381-0645.
I AUTHORIZE, WITHOUT RESERVATION, HireRight, AND ANY PARTY OR AGENCY CONTACTED BY HireRight, TO FURNISH THE ABOVE-MENTIONED INFORMATION. This authorization does not apply to drug and alcohol information obtained under Part I.
I hereby consent to your obtaining the above information from HireRight, and I agree that such information which HireRight has or obtains, and my employment history (not DOT Drug and Alcohol information without a specific consent by me) with you if I am hired, will be supplied by HireRight to other companies which subscribe to HireRight. I hereby authorize procurement of consumer report(s) if hired or contracted by this authorization. For Part II reports only, shall remain on file and shall serve as ongoing authorization for you to procure consumer reports at any time during my employment or contract period
PART III – POST-ACCIDENT TESTING§382.303 Post-accident testing.
(a) As soon as practicable following an occurrence involving a commercial motor vehicle operating on a public road in commerce, each employer shall test for alcohol for each of its surviving drivers:
(a)(1) Who was performing safety-sensitive functions with respect to the vehicle, if the accident involved the loss of human life; or(a)(2) Who receives a citation within 8 hours of the occurrence under State or local law for a moving traffic violation arising from the accident, if the accident involved:
(a)(2)(i) Bodily injury to any person who, as a result of the injury, immediately receives medical treatment away from the scene of the accident; or(a)(2)(ii) One or more motor vehicles incurring disabling damage as a result of the accident, requiring the motor vehicle to be transported away from the scene by a tow truck or other motor vehicle.(b) As soon as practicable following an occurrence involving a commercial motor vehicle operating on a public road in commerce, each employer shall test for controlled substances for each of its surviving drivers:(b)(1) Who was performing safety-sensitive functions with respect to the vehicle, if the accident involved the loss of human life; or(b)(2) Who receives a citation within thirty-two hours of the occurrence under State or local law for a moving traffic violation arising from the accident, if the accident involved:(b)(2)(i) Bodily injury to any person who, as a result of the injury, immediately receives medical treatment away from the scene of the accident; or(b)(2)(ii) One or more motor vehicles incurring disabling damage as a result of the accident, requiring the motor vehicle to be transported away from the scene by a tow truck or other motor vehicle.(c) The following table notes when a post-accident test is required to be conducted by paragraphs (a)(1), (a)(2), (b)(1), and (b)(2) of this section:
Table for §382.303 (A) and (B)
(d)(1) Alcohol tests. If a test required by this section is not administered within two hours following the accident, the employer shall prepare and maintain on file a record stating the reasons the test was not promptly administered. If a test required by this section is not administered within eight hours following the accident, the employer shall cease attempts to administer an alcohol test and shall prepare and maintain the same record. Records shall be submitted to the FMCSA upon request.
(d)(2) Controlled substance tests. If a test required by this section is not administered within 32 hours following the accident, the employer shall cease attempts to administer a controlled substances test, and prepare and maintain on file a record stating the reasons the test was not promptly administered. Records shall be submitted to the FMCSA upon request.
(e) A driver who is subject to post-accident testing shall remain readily available for such testing or may be deemed by the employer to have refused to submit to testing. Nothing in this section shall be construed to require the delay of necessary medical attention for injured people following an accident or to prohibit a driver from leaving the scene of an accident for the period necessary to obtain assistance in responding to the accident, or to obtain necessary emergency medical care.
(f) An employer shall provide drivers with necessary post-accident information, procedures and instructions, prior to the driver operating a commercial motor vehicle, so that drivers will be able to comply with the requirements of this section.
(g)(1) The results of a breath or blood test for the use of alcohol, conducted by Federal, State, or local officials having independent authority for the test, shall be considered to meet the requirements of this section, provided such tests conform to the applicable Federal, State or local alcohol testing requirements, and that the results of the tests are obtained by the employer.
(g)(2) The results of a urine test for the use of controlled substances, conducted by Federal, State, or local officials having independent authority for the test, shall be considered to meet the requirements of this section, provided such tests conform to the applicable Federal, State or local controlled substances testing requirements, and that the results of the tests are obtained by the employer.
(h) Exception. This section does not apply to:(h)(1) An occurrence involving only boarding or alighting from a stationary motor vehicle; or(h)(2) An occurrence involving only the loading or unloading of cargo; or(h)(3) An occurrence in the course of the operation of a passenger car or a multipurpose passenger vehicle (as defined in §571.3 of this title) by an employer unless the motor vehicle is transporting passengers for hire or hazardous materials of a type and quantity that require the motor vehicle to be marked or placarded in accordance with §177.823 of this title.
THE BELOW DISCLOSURE AND AUTHORIZATION LANGUAGEIS FOR MANDATORY USE BY ALL ACCOUNT HOLDERS
IMPORTANT DISCLOSURE REGARDING BACKGROUND REPORTSFROM THE PSP Online Service
In connection with your application for employment with TruCore Energy LLC, Prospective Employer, its employees, agents or contractors may obtain one or more reports regarding your driving, and safety inspection history from the Federal Motor Carrier Safety Administration (FMCSA)
When the application for employment is submitted in person, if the Prospective Employer uses any information it obtains from FMCSA in a decision to not hire you or to make any other adverse employment decision regarding you, the Prospective Employer will provide you with a copy of the report upon which its decision was based and a written summary of your rights under the Fair Credit Reporting Act before taking any final adverse action. If any final adverse action is taken against you based upon your driving history or safety report, the Prospective Employer will notify you that the action has been taken and that the action was based in part or in whole on this report.
When the application for employment is submitted by mail, telephone, computer, or other similar means, if the Prospective Employer uses any information it obtains from FMCSA in a decision to not hire you or to make any other adverse employment decision regarding you, the Prospective Employer must provide you within three business days of taking adverse action oral, written or electronic notification: that adverse action has been taken based in whole or in part on information obtained from FMCSA; the name, address, and the toll free telephone number of FMCSA; that the FMCSA did not make the decision to take the adverse action and is unable to provide you the specific reasons why the adverse action was taken; and that you may, upon providing proper identification, request a free copy of the report and may dispute with the FMCSA the accuracy or completeness of any information or report. If you request a copy of a driver record from the Prospective Employer who procured the report, then, within 3 business days of receiving your request, together with proper identification, the Prospective Employer must send or provide to you a copy of your report and a summary of your rights under theFair Credit Reporting Act.
Neither the Prospective Employer nor the FMCSA contractor supplying the crash and safety information has the capability to correct any safety data that appears to be incorrect. You may challenge the accuracy of the data by submitting a request to https://dataqs.fmcsa.dot.gov. If you challenge crash or inspection information reported by a State, FMCSA cannot change or correct this data. Your request will be forwarded by the DataQs system to the appropriate State for adjudication.
Any crash or inspection in which you were involved will display on your PSP report. Since the PSP report does not report, or assign, or imply fault, it will include all Commercial Motor Vehicle (CMV) crashes where you were a driver or co-driver and where those crashes were reported to FMCSA, regardless of fault. Similarly, all inspections, with or without violations, appear on the PSP report. State citations associated with Federal Motor Carrier Safety Regulations (FMCSR) violations that have been adjudicated by a court of law will also appear, and remain, on a PSP report.
The Prospective Employer cannot obtain background reports from FMCSA without your authorization.
If you agree that the Prospective Employer may obtain such background reports, please read the following and sign below:
I authorize TruCore Energy to access the FMCSA Pre-Employment Screening Program (PSP) system to seek information regarding my commercial driving safety record and information regarding my safety inspection history. I understand that I am authorizing the release of safety performance information including crash data from the previous five (5) years and inspection history from the previous three (3) years. I understand and acknowledge that this release of information may assist the Prospective Employer to make a determination regarding my suitability as an employee.
I further understand that neither the Prospective Employer nor the FMCSA contractor supplying the crash and safety information has the capability to correct any safety data that appears to be incorrect. I understand I may challenge the accuracy of the data by submitting a request to https://dataqs.fmcsa.dot.gov. If I challenge crash or inspection information reported by a State, FMCSA cannot change or correct this data. I understand my request will be forwarded by the DataQs system to the appropriate State for adjudication.
I understand that any crash or inspection in which I was involved will display on my PSP report. Since the PSP report does not report, or assign, or imply fault, I acknowledge it will include all CMV crashes where I was a driver or co-driver and where those crashes were reported to FMCSA, regardless of fault. Similarly, I understand all inspections, with or without violations, will appear on my PSP report, and State citations associated with FMCSR violations that have been adjudicated by a court of law will also appear, and remain, on my PSP report. I have read the above Disclosure Regarding Background Reports provided to me by Prospective Employer and I understand that if I sign this Disclosure and Authorization, Prospective Employer may obtain a report of my crash and inspection history. I hereby authorize Prospective Employer and its employees, authorized agents, and/or affiliates to obtain the information authorized above.
DRIVER STATEMENT OF ON-DUTY HOURS
(For Newly Hired Drivers)
INSTRUCTIONS: Motor carriers when using a driver for the first time shall obtain from the driver a signed statement giving the total time on-duty during the immediate preceding 7 days and time at which such driver was last relieved from duty prior to beginning work for such carrier. Rule 395.8(j)(2) Federal Motor Carrier Safety Regulations. NOTE: Hours for any compensated work during the preceding 7 days, including work for non-motor carrier entity, must be recorded on this form.
Motor Vehicle Operator’s License Number:
Type of License: Issuing State:
I hereby certify that the information given above is correct to the best of my knowledge and belief, and that I was last relieved at work at: AM PM
DRIVER CERTIFICATION FOR OTHER COMPENSATED WORK
INSTRUCTIONS: When employed by a motor carrier, a driver must report to the carrier all on-duty time including time working for other employers. The definition of on-duty time found in Section 395.2(8)(9) of the Federal Motor Carrier Safety Regulations, includes time performing any other work in the capacity of, or in the employ or service of, a common, contract or private motor carrier, also performing any compensated work for any non-motor carrier entity.
Please list at least two contacts
RELEASE OF CDL HOLDER’S REPORTED
POSITIVE ALCOHOL OR CONTROLLED
SUBSTANCE TEST RESULTS
This form should ONLY be used if you wish to inquire whether or not prospective driver (CDL Holder)
has had a positive alcohol or controled substance test result reported to the Texas Department of Public Safety in compliance with state low
Texas Department of Public Safety
Motor Carrier Bureau, MSC #0521
6200 Guadalupe, Building P
Austin, Texas 78752-4019/Facsimile: 512-424-5310
Print name of CDL Holder
Print full Address, City, State, and Zip of CDL Holder
Driver License Number of CDL Holder
Date of Birth
authorize release of any and all of CDN holder’s reported positive alcohol or controlled substance test result reported under Texas state law to
3139 CR 205 N Henderson, TX 75652
Leave this empty:
If you have questions about the contents of this document, you can email the document owner.
Document Name: Application
Agree & Sign