CONFIDENTIAL DRUG
& ALCHOHOL TESTING
CONSENT TO RELEASE
INFORMATION
DOT REGULATION 49 CFR
Part 40.25
Full Name: __________________________________________ Social Security #: _________________________
Address: ___________________________________________
Telephone #:
_____________________________
____________________________________________
Signature: ___________________________________________
Date:_______________
I hereby authorize my previous employer(s) that are covered by Department of Transportation Drug Testing Regulations
(listed below-list all employers for the previous 24 months)
Greystone Health Sciences, Inc. and Pretiem (MIB) to release
the following information
with regard to my chemical testing records to my prospective employer:
1
Name
of Previous Employer: ________________________________________________
Company
Contact Person: __________________________________________________
Telephone
#: _________________________ Fax #: _____________________________
Date
of employment: __________________ Date of Discharge: ____________________
2.
Name of Previous Employer:
________________________________________________
Company
Contact Person: __________________________________________________
Telephone
#: _________________________ Fax #: _____________________________
Date
of employment: __________________ Date of Discharge: ____________________
3. Name of Previous Employer:
________________________________________________
Company
Contact Person: __________________________________________________
Telephone
#: _________________________ Fax #: _____________________________
Date
of employment: __________________ Date of Discharge: ____________________
4. Name of Previous Employer:
________________________________________________
Company
Contact Person: __________________________________________________
Telephone
#: _________________________ Fax #: _____________________________
Date
of employment: __________________ Date of Discharge: ____________________
If you need more space, attach separate
sheet.