Please print this form, sign it and fax or mail to
Millis Transfer Inc.
PO Box 550
Black River Falls, Wi. 54615
AUTHORIZATION FOR THE RELEASE OF INFORMATION
Drivers Name ____________________________
Date of Birth_________________ Social Security#______________________
Prior Employer:________________________ Address________________________________________________
In accordance with 49 CFR 382.405(f) and 382.413(b), you are hereby authorized and requested to release to Millis Transfer, Inc. at PO Box 550, Black River Falls, WI any and all information in your possession concerning participation in a drug and alcohol testing program under 49 CFR Part 382. I specifically authorize you to release information on any alcohol tests with concentration results of 0.04 or greater, positive controlled substance test results and / or refusals to be tested within three years preceding the date of this request. This authorization also permits the disclosure of any drug or alcohol test results and / or refusals to be tested not specifically within the mandatory disclosure requirements of 49 CFR 382.413(B), including the results of any drug tests conducted under 49 CFR part 391, Subpart H, as well as records of any of the above information that have been received by the employer from any other sources, including records from other employers.
I further authorize and request you to release any information in your possession concerning my evaluation by a substance abuse professional, the identity of that substance abuse professional, and my participation in any treatment or rehabilitation recommended by the substance abuse professional and the results of any return-to-duty or follow-up drug and / or alcohol test within the three years preceding this request. I also authorize any substance abuse professional identified herein to release any of the above information to the above listed employer.
A photocopy of this release shall be valid as the original. This authorization shall be valid for one year from the date of signing hereof.
Date Driver Signature