_________________________________________________ ______________________________________
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)
