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DOT Drug & Alcohol Testing Acknowledgment

Disclaimer:
This form is used to collect self-reported acknowledgments related to DOT-mandated drug and alcohol testing. WIZ Test LLC does not provide legal advice, does not certify compliance, and relies on the accuracy of information provided by the individual completing this form.
Full Legal Name(Required)
Date of Birth(Required)
MM slash DD slash YYYY
Test Type (select all that apply)(Required)
Affirmation – DOT Regulations(Required)
Affirmation – Specimen Integrity(Required)
Affirmation – Consent(Required)
Affirmation – Perjury(Required)
MM slash DD slash YYYY
By typing your full legal name, you acknowledge and affirm the statements above.

DOT Drug & Alcohol Testing Application Form

(49 CFR Part 40 – DOT Regulated Testing)
SECTION A – APPLICANT INFORMATION
Date of Birth (MM/DD/YYYY)(Required)
MM slash DD slash YYYY
Enter last 4 digits only.
Home Address(Required)
SECTION B – EMPLOYMENT & DOT INFORMATION
Employer Address
DOT Agency (check one)(Required)
Expiration Date
MM slash DD slash YYYY
SECTION C – TESTING REQUIREMENTS
Type of Test (check all that apply)(Required)
Type of Specimen(Required)
SECTION D – MEDICATION DISCLOSURE (FOR MRO REVIEW)
Prescription medications taken in the last 30 days
If you have medications to disclose, leave “None” unchecked and list them below.
SECTION E – DOT CONSENT & ACKNOWLEDGMENTS
Please read carefully and initial each statement:
Initial to acknowledge(Required)
I understand that this test is conducted under U.S. Department of Transportation regulations (49 CFR Part 40).
Initial to acknowledge(Required)
I consent to the collection and testing of my specimen using DOT-approved procedures.
Initial to acknowledge(Required)
I certify that the specimen I provide will be my own, and that I will not attempt to substitute, adulterate, or tamper with the specimen.
Initial to acknowledge(Required)
I understand that refusal to test, failure to cooperate, or engaging in prohibited conduct constitutes a DOT Refusal to Test, which will be reported to my employer.
Initial to acknowledge(Required)
I understand that test results will be reviewed by a DOT-certified Medical Review Officer (MRO).
Initial to acknowledge(Required)
I authorize the release of test results to my employer, the MRO, and other authorized parties as permitted by DOT regulations and federal law.
Initial to acknowledge(Required)
I understand that medical information is confidential and will not be released to my employer without my consent, except as allowed by DOT regulations.
Initial to acknowledge(Required)
I acknowledge that providing false information may result in removal from safety-sensitive duties and other regulatory consequences.
SECTION F – APPLICANT CERTIFICATION
I certify that the information provided in this application is true and complete to the best of my knowledge and understand that this application supports the execution of a DOT Drug Testing Affidavit.
By typing your full legal name, you acknowledge and affirm the statements above.
Date(Required)
MM slash DD slash YYYY

Mailing Address

Wiz Test LLC
1315 Clinton Street
Attica, NY 14011

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