Form

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APPLICANT'S/TRANSFEREE’S AUTHORIZATION TO OBTAIN

DRUG AND ALCOHOL-RELATED INFORMATION FROM

PREVIOUS DOT-REGULATED EMPLOYERS

I, ira mccormack, understand that as a condition of hire or engagement with gcc

[insert applicant's name] ira mccormack, I must give the Company written authorization to obtain [insert Company name] certain drug and alcohol-related information from all of the past DOT-regulated employers for which I worked as a commercial motor vehicle (CMV) driver or in another DOT-regulated safety sensitive position during the past three (3) years. I have also been advised and understand that my signing of this authorization does not guarantee that I will be offered a position with the Company, or continued employment by the Company, or that I will be given other opportunities to work for or on behalf of the Company.

I hereby authorize the Company to obtain the following information from each of the DOT- regulated employers for which I worked as a CMV driver, or in any other DOT-regulated safety-sensitive position during the past three (3) years:

(i) whether, within the previous three years, I have violated DOT's or FMCSA's drug and alcohol prohibitions, including but not limited to: (A) all verified positive drug (controlled substances) test results; (B) all alcohol test results of 0.04 concentration or greater; (C) all instances in which I refused to submit to a DOT-required drug and/or alcohol test (including verified adulterated or substituted drug test results); (D) all other violations of DOT agency drug and alcohol testing regulations;

(ii) whether I failed to undertake or complete a rehabilitation program prescribed by a substance abuse professional (SAP) pursuant to DOT's and FMCSA's return-to-duty requirements. If the previous employer does not know this information, I understand that I must provide documentation of successful completion of the SAP's referral directly to the Company.

(iii) If I successfully completed a SAP's rehabilitation referral, and remained in the employ of the referring employer, information on whether I had the following testing violations subsequent to completion of the referral process: (A) alcohol tests with a result of .04 or higher alcohol concentration; (B) verified positive drug tests; (C) refusals to be tested

(including verified adulterated or substituted drug test results). I authorize each of my previous employers to release the above information to the Company, in writing, addressed to Sterling Infosystems and marked “Confidential.” I further authorize each of my previous employers to release the above-specific drug and alcohol-related information which they obtained from any other DOT-regulated employer for whom I worked as a CMV driver, or in another DOT-regulated safety-sensitive position, during the past three (3) years.

Below I have provided the name and address of a DOT-regulated employer for which I worked as a CMV driver or in another DOT-regulated safety-sensitive position during the past three (3) years:

Company name and address Dates worked for/or applied to __DEcker Truck lines

Reason(s) for Leaving (if applicable): Contact's Name: __any

I agree to execute a separate authorization for each DOT-regulated employer for which I worked as a CMV driver or in another DOT-regulated safety-sensitive position during the past three (3) years.

I further understand that I have the following rights regarding the investigative information that will be provided to the Company: (1) the right to review information provided by previous employers; (2) the right to have errors in the information corrected by the previous employer and for that previous employer to re-send the corrected information to the Company; (3) the right to have a rebuttal statement attached to the alleged erroneous information, if the previous employer and I cannot agree on the accuracy of the information. I understand that if I wish to review previous employer-provided investigative information, I must submit a written request to the Company, no later than 30 days after being employed or being notified of denial of employment. The Company will provide the requested investigative information to me within five business days of receiving the written request, or within five business days of receipt of the requested information from the previous employer, whichever is later. APPLICANT’S/TRANSFEREE’S

CERTIFICATION:

I have carefully read and fully understand this authorization to release my past drug and alcohol- related information, as specified above. In signing below, I certify that all of the information which I have furnished on this form is true and complete. I understand that this authorization will be sent to my former employer listed above. ism

5/22/2020 Signature of

applicant/transferee Date

_ira scott

mccormack

Print Name

15401155v

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