Drug & Alcohol pg - Drake Farms Trucking

Driver Application Drug and Alcohol PRE-Employment statement

CFRPart40.25{j)requires the employer to ask any driver applicant, whether he or she has tested positive, or refused to test, on any pre-employment drug or alcohol test administered by an employer to which the employee applied for, but did not obtain, safety-sensitive transportation work covered by DOT agency drug and alcohol rules during the past two years. If the potential employee admits that he or she had a positive test or refusal to test, employers must not use the employee, if hired, to perform safety-sensitive junctions, until and unless the potential employee provides documentation of successful completion of the return-to-duty process. (See CFR 40.25(b)(5) and (e)).

Applicant Name:*

Since you are applying to perform safety-sensitive functions for our company, we are required by the CFR Part 40.25(j), to ask the following questions:

OK

1. Have you tested positive, or refused to test, on any pre-employment drug or alcohol test administered by an employer to which you applied for, but did not obtain, safety-sensitive transportation work covered by DOT agency drug and alcohol testing rules during the past two (2) years? *

Yes
No

2. If you answered yes to the above question, can you provide proof that you have seccessfully completed the DOT return-to-duty requirments? *

Yes
No
N/A

Name (First and Last name)*

Email address

My acknowledgement below certified that the information provided is true and correct.*

Great West Casualty Company does not provide legal advice to its customers, nor does it advise insureds on employment related issues, therefore the 
Subject matter is not intended to serve as legal or employment advice for any issuers) that may arise in the operations of its insureds. Legal advice 
should always be sought from the insured's legal counsel Great West Casualty Company shall have neither liability nor responsibility to any person 
or entity with respect to any loss, action or inaction alleged to be caused directly or indirectly as a result of the information contained herein.

I agree