Consent Form PRE-EMPLOYMENT URINALYSIS
I understand that as required by the Federal Motor Carrier Safety Regulations Title 49 US Code of Federal Regulations
Section 391,103,and company policy, all prospective drivers must submit to a controlled substances test. A urine sample
will be collected and tested for controlled substances. I also understand that if test positive for use of controlled
substances, I am not medically qualified to operate a commercial motor vehicle. The results of the drug test will be
maintained by the Medical Review Officer or the company who will report whether the test results were negative or
positive to the motor carrier. The results will not be released to any additional parties without my written authorization.
I HERBALY CERTIFY THAT I HAVE READ AND UNDERSTOOD ABOVE REQUIREMENT. (CIRCLE YES or NO)
• YES -I agree with above requirement.
• NO -I do not agree with above requirement
Applicant printed name
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Applicant’s signature
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DATE
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REQUEST FOR CHECK OF DRIVING RECORD
I HEREBY AUTHORIZE YOU TO RELEASE THE FOLLOWING INFORMATION TO OFAH Inc DBA White City Logistics Inc FOR PURPOSES OF
INVESTIGATION AS REQUIRED BY SECTIONS 391.23 AND 391.25 OF THE FEDERAL MOTOR CARRIER SAFETY REGULATIONS. YOU ARE
RELEASED FROM ANY AND ALL LIABILITY WHICH MAY RESULT FROM FURNISHING SUCH AN INFORMATION.
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(Applicant`s Signature)
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DATE
IN ACCORDANCE WITH THE PROVISIONS OF SECTIONS 604 AND 607 OF THE FAIR CREDIT REPORTING ACT, PUBLIC LAW 91-508, AS AMENDED BY THE
CONSUMER CREDIT REPORTING ACT OF 1996 (TITLE II, SUBTITLE D, CHAPTER 1, OF PUBLIC LAW 104-208), I HEREBY CERTIFY THE FOLLOWING:
1. THE CONSUMER (APPLICANT) HAS AUTHORIZED IN WRITING THE PROCUREMENT OF THIS REPORT;
2. THE CONSUMER (APPLICANT) HAS BEEN INFORMED IN A SEPARATE WRITTEN DISCLOSURE THAT A CONSUMER REPORT MAY BE
OBTAINED FOR EMPLOYMENT PURPOSES;
3. THE INFORMATION REQUESTED BELOW WILL BE USED FOR A “PERMISSIBLE PURPOSE” (I.E., INFORMATION FOR EMPLOYMENT
PURPOSES) AND WILL BE USED FOR NO OTHER PURPOSE;
4. THE INFORMATION BEING OBTAINED WILL NOT BE USED IN VIOLATION OF ANY FEDERAL OR STATE EQUAL OPPORTUNITY LAW
OR REGULATION; AND
5. BEFORE TAKING AN ADVERSE ACTION BASED IN WHOLE OR IN PART ON THE REPORT THE CONSUMER (APPLICANT) WILL
RECEIVE A COPY OF THE REQUESTED REPORT AND THE SUMMARY OF CONSUMER RIGHTS AS PROVIDED WITH THE REPORT BY
THE CONSUMER REPORTING AGENCY.
I ALSO HEREBY CERTIFY THAT THIS REPORT REQUEST AND THE ABOVE APPLICANT’S RELEASE NOTICE MEET THE DEFINITION OF
“PERMISSIBLE USES” OF STATE MOTOR VEHICLE RECORDS UNDER THE PROVISIONS OF THE DRIVER’S PRIVACY PROTECTION ACT OF
1994 (PUBLIC LAW 103-322, TITLE XXX, SECTION 300002(A)).
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(Signature of Requester)
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DATE
