• Tampa, FL
  • Phone 813-251-5100
  • 3670 S West Shore Blvd. Tampa FL 33629

EMPLOYEE CONSENT FORM

EMPLOYEE CONSENT FORM

  • I hereby authorize:

    a) my previous employer(s) (listed below – please list all your DOT/USCG employers for the previous 24 months 1 ), and Greystone Health Sciences, Inc., to release the following information with regard to my chemical testing records to Pretiem/Hirecheck and/or my prospective employer Dann Ocean Towing, Inc.
    AND

    b) Pretiem/Hirecheck to release the following information with regard to my chemical testing records to my prospective employer listed above:

    a) alcohol tests with a result of 0.04 or higher alcohol concentration,
    b) verified positive drug tests,
    c) refusals to test including verified adulterated or substituted drug test results,
    d) any other violations of DOT/USCG drug and alcohol testing regulations, and
    e) with respect to any violation of a DOT/USCG chemical testing regulation, documentation of my completion of DOT return-to-duty requirements including follow up tests.

  • 1.

  • 2.

  • 3.

  • EMPLOYEE CERTIFICATION


    Pursuant to US Department of Transportation Regulation (“DOT”), 49 CFR part 40.25, paragraph “J,” you must respond truthfully to the following questions. During the past two years (24 months), with respect to DOT/USCG pre-employmentdrug or alcohol testing have you:
  • With respect to any violation of a DOT/USCG chemical testing regulation, please provide documentation of your completion of DOT return-to-duty requirements including follow up tests (Please enclose documentation)
    If you answered YES to any of these questions, please provide Dann Ocean Towing, Inc. with the following information:
  • I certify that the above statements are true under penalty of loss of the position applied for.

  • FOR PREVIOUS EMPLOYER(S) USE ONLY

  • The applicant listed above has authorized your organization to release the following information. During the past two years (24 months), with respect to the DOT’s chemical testing regulations, did the applicant/employee:
  • With respect to any violation of a DOT/USCG chemical testing regulation, please provide documentation of the applicant’s completion of DOT return-to-duty requirements including follow up tests.
    If you answered YES to any of these questions, please provide Dann Ocean Towing, Inc. with the following information: