10_CDLHolderReported

RELEASE OF CDL HOLDER'S REPORTED POSITIVE ALCOHOL OR CONTROLLED SUBSTANCE TEST RESULTS
Use this form to obtain the CDL holder's reported positive alcohol or controlled substance test results information.

This form should ONLY be used if you wish to inquire whether or not a prospective driver (CDL Holder) has had a positive alcohol or controlled substance test result reported to the Texas Department of Public Safety in compliance with state law.

THIS FORM IS NOT REQUIRED FOR REPORTING A POSITIVE ALCOHOL OR CONTROLLED SUBSTANCE TEST.

1. This form must be completed in full and include the driver's original signature. (Electronic signatures will not be accepted)

2. Deliver, mail, Email or FAX the completed form to:

Texas Department of Public Safety

Motor Carrier Bureau, MSC #0521

6200 Guadalupe, Building P

Austin, Texas 78752-4019 / Facsimile: 512-424-5310

Email: MCB.VPR@dps.texas.gov
Check here if CDL. Holder is requesting results on self
Print Name of CDL Holder
,
Print full Address City State and Zip Code of CDL Holder
Social Security
Driver License Number of CDL Holder
State
Date of Birth

MonthDayYear
Date
authorize release of any and all of CDL holder's reported positive alcohol or controlled substance test results reported under Texas state law to

BRAVO MOTOR CARRIERS INC (281) 768-8843

9009 North Loop East Ste. 200 Houston TX 77029
Signature of Driver

Clear
Date

MonthDayYear
Date
If you wish to request and receive this information by electronic mail, submit a completed and notarized Electronic Mail Verification Form (MCS-32), available at the following web address: http://www.dps.texas.gov.htm. MCS-21 (Rev 10/17)
Should be Empty:

RELEASE OF CDL HOLDER'S REPORTED POSITIVE ALCOHOL OR CONTROLLED SUBSTANCE TEST RESULTS