4

Safety Performance H istory lnvestigation Waiver

t, *te+ u (rH€ rA c€4 hdreby authorize to release the

following information requested by-this document concerning my past employment record and
from my Department of Transportation regulated Drug and lcofr-oi testing redords to:

i
" Fulger Transport lnc.
4016 County Rd.23
Essex, Ontario, Ganada, N8M 2X7
Phone: 3i3-651-2156
Fax:866-58749A9

This release is in accordance with D.O.T. Regulation 49CFR part 40, section 4O.2S.l understand
that information to be released by my previous employer is limited to the following D.O.T.
regulated testing items:
1. Alcohol tests with a result of 0.04 or higher
2. Verified positive drug tests
3. Refusals to be tested
4. Otherviolations of DOT agency drug and alcohol rule violation
5. Documentation, if an!,:6f completion of the return - to duty process following a rule
violation

I further authorize my former employerto release all information concerning my employment

lcl,uding my safety performance history information (investigation purposJs ai requirld by
FMCSR 391.23,382.405 (0 and 382.413 (b)), oral assessments of my job pertormance, abiligr and
fitness to each and every company'wfrich may request such information in connection with my
job application with Fulger Transport lnc.

I hereby release you fiom any and all tiability of any type as a result of providing the above
mentioned information to the above mentioned company or its representative. A photocopy of this
release shall be as valid as the original.

Applicants Signature Oate oA/ o//L,c