PREVIOUS PRE-EMPLOYMENT EMPLOYEE ALCOHOL AND DRUG TEST STATEMENT

PREVIOUS PRE-EMPLOYMENT EMPLOYEE ALCOHOL AND DRUG TEST STATEMENT
By providing the information requested below and signing this document, you acknowledge and agree to the following:

You authorize Starr Transit to collect and use the information provided herein for the purposes stated in this document. You certify that all information provided is accurate and complete to the best of your knowledge. Your electronic or physical signature on this document signifies your consent and agreement to the terms outlined herein.
Sec. 40.25(j) As the employer, you must also ask the employee whether he or she has tested positive, or refused to test, on any pre-employment drug or alcohol test administered by an employer to which the employee applied for, but did not obtain, safety-sensitive transportation work covered byDOT agency drug and alcohol testing rules during the past two years. If the employee admits that he or she had a positive test or a refusal to test, you must not use the employee to perform safety-sensitive functions for you, until and unless the employee documents successful completion of the return-to-duty process. (see Sec 40.25(b)(5) and (e))
Prospective Employee Name (Please Print):

First NameLast Name
ID Number:
The prospective employee is required by Sec 40.25(j) to respond to the following questions.
Have you tested positive, or refused to test, on any pre-employment drug or alcohol test administered by an employer to which you applied for, but did not obtain, safety-sensitive transportation work covered by DOT agency drug and alcohol testing rules during the past two years?

YesNo
If you answered yes, can you provide or obtain proof that you have successfully completed the DOT return-to-duty requirements?

YesNo
I certify that the information provided in this document is true and correct.
Prospective Employee Signature:

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Witnessed By:

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Should be Empty: