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PREVIOUS PRE-EMPLOYMENT EMPLOYEE ALCOHOL <br />AND DRUG TEST STATEMENT <br />S:\Accounting\FoRMS\Applications\Previous Pre-Employment Employee Alcohol and Drug Test Statement,docx <br />Sec. 40.25O Visu-Sewer, Inc. is required as an employer to ask you whether you have tested positive, or <br />refused to test, on any pre-employment drug or alcohol test administered by an employer to which you <br />have applied for, but did not obtain, safety-sensitive transportation work covered by DOT agency drug <br />and alcohol testing rules during the past two years. If you admit that you had a positive test or refused to <br />be tested, you may not be employed by Visu-Sewer to perform safety-sensitive functions, until and <br />unless you document successful completion of the return-to-duty process (see Sec. 40.25(bX5) and (e). <br />As a prospective employee, you are required by Sec. 40.250) to respond to the following questions. <br />1)Have you ever tested positive or refused to test, on any pre-employment drug or alcohol test <br />administered by an employer to which you applied for, but did not obtain, safety sensitive <br />transportation work covered by DOT agency drug and alcohol testing rules during the past two <br />years? <br />Check One: Yes No <br />2)If you answered yes, can you provide/obtain proof that you have successfully completed the DOT <br />return-to -duty requirements? <br />Check One: Yes No <br />I certify that the information provided on this document is true and correct. <br />Applicant's Print Name Social Security Number <br />DateApplicant's Signature <br />APPENDIX E