Page 152 - Personnel Policy and Procedures Manual

Information Request Form (Pre-Employment Transit)

I, hereby allow Augusta, Georgia Transit
(Applicant) (Transit Agency)
to contact my former DOT -regulated employer(s), from the past two years, to request the following
information in accordance with 49CFR part 40.25.

1. Alcohol test results of 0.04 or higher alcohol concentration. 49CFR part 40.25(b)(1)
2. Verified positive drug tests. 49CFR part 40.25(b)(2)
3. Refusals to be tested (including verified adulterated or substituted drug test results.)
49CFR part 40.25(b)(3)
4. Other violations of DOT agency drug and alcohol testing regulations. 49CFR part
40.25(b)(4)
5. With respect to any employee who violated a DOT drug and alcohol regulation,
Documentation of the employee's successful completion of DOT return-to-duty
Requirements (including follow-up tests). 49CFR part 40.25(b)(5)

Please list former employer(s) with contact information.

In respect to DOT drug and alcohol testing regulations over the past two years……

Have you ever had an alcohol test results of 0.04 or higher? Yes No
Have you ever had a verified positive drug test? Yes No
Have you ever refused to be tested (including verified adulterated or
substituted drug test results.) Yes No
Have you violated any DOT agency drug and alcohol testing regulation? Yes No

If you have violated a DOT drug and alcohol regulation, do you have documentation of successful
completion of DOT return-to-duty requirements (including follow-up tests)?
Yes No

FAILURE TO PROVIDE WRITTEN CONSENT, INCLUDING FORMER EMPLOYER(S)
INFORMATION, ANSWERS TO THE QUESTIONS AND SIGNATURE, WILL RESULT IN
YOU BEING DISQUALIFIED FOR A SAFETY SENSITIVE POSITION WITH AUGUSTA,
GEORGIA TRANSIT, AS PER 49CFR PART 40.25(a).

Applicant Signature Date

Witness Signature Date

FORM SA-7

All Rights Reserved – As approved by the Commission on 05-07-2019 152 | P a g e