Novco Inc.
11090 173rd Ave NW
Elk River, MN
55330
RELEASE FOR
VERIFICATION STATEMENTS
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Applicant’s Name (Printed) Applicant’s Social Security No. Date
I authorize NOVCO, INC. to make such investigations and inquiries of my personal, employment, financial or medical history and other related matters as may be necessary in arriving at an employment decision. (Generally, inquires regarding medical history will be made only if and after a conditional offer of employment has been extended.)
I hereby authorize you to release the following information to NOVCO, INC. for the purposes of investigation as required by Section 391.23 and 382.413 of the Federal Motor Carrier Safety Regulations. I do hereby release the company supplying this information from all liability as a result of releasing truthful information in compliance with this request.
The information that I have authorized NOVCO, INC to review involves test required by DOT. If any carrier (company and /or school) furnishes NOVCO, INC. with information concerning items (1) through (6) above, I also authorize that carrier (company and/or school) to release and furnish the date of my negative drug and/or alcohol test and/or test with results below 0.04 during the three (3) year period and the name and phone number of any substance abuse profession who evaluated me during the past three (3) years.
By signing below, I authorize, per 49 CFR Part 40, the release of information from my DOT regulated drug and alcohol testing records by carriers, companies and/or schools to NOVCO, INC. I authorize the following information concerning DOT drub and alcohol testing violations including pre-employment test during the past three (3) years: (1) alcohol test with a result of 0.04 or higher; (2) verified positive drug test; (3) refusals to be tested (including verified adulterated or substituted results) (4) other violations of DOT drug and alcohol testing regulations; (5) information obtained from previous employers of a drug and alcohol rule violation(s); and (6) documents, if any, of completion of a return-to-duty process following a rule violation.
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Applicants Signature Date