General Consent for Limited Queries of
the Federal Motor Carrier Safety Administration (FMCSA)
Drug and Alcohol Clearinghouse
I, , hereby provide consent to the Company listed below (herein
"Company") to conduct a limited query of the FMCSA Commercial Driver’s License Drug and
Alcohol Clearinghouse to determine whether drug or alcohol violation information about me
exists in the Clearinghouse. This consent authorizes the Company to conduct multiple limited
queries for the duration of my employment with the Company. The number of queries authorized
is unlimited, unless otherwise specified.
I understand that if the limited query conducted by the Company indicates that drug or alcohol
violation information about me exists in the Clearinghouse, FMCSA will not disclose that
information to the Company without first obtaining additional specific consent from me.
I further understand that if I refuse to provide consent for the Company to conduct a limited query
of the Clearinghouse, the Company must prohibit me from performing safety-sensitive functions,
including driving a commercial motor vehicle, as required by FMCSA’s drug and alcohol program
regulations.
Employee Signature
Date
Driver's License Number
State of Issue Date of Birth
Company Name
Company Phone Number
Company Street Address
Company City, State & Zip Code
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