403.7E3 - Certification of Previous Employers Requiring a Commercial Driver’s License Consent to Release Information to Independence Community School District

_________________________________________________         ______________________________________
                                 Name                                                                                     Social Security Number

 

I certify that I have been employed by the following employers during the two years prior to the date stated below and that I was required to possess a commercial driver’s license (CDL) and submit to drug and alcohol testing during the term of my employment.

 

Company  _____________________________________________________________________

Address  ______________________________________________________________________

City/State/Zip  _________________________________________________________________

 

Company  _____________________________________________________________________

Address  ______________________________________________________________________

City/State/Zip  _________________________________________________________________

 

Company  _____________________________________________________________________

Address  ______________________________________________________________________

City/State/Zip  _________________________________________________________________

 

I hereby release my records pertaining to my driving and drug and alcohol testing results.

 

_________________________________________________     ______________________________
(Signature)                                                                                                              (Date)