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80 <br /> <br />** As an applicant I understand I will need to register with the FMCSA Clearinghouse to complete the <br />registration process before I can respond to employer consent requests or <br />access my driver record in the FMCSA Commercial Driver’s License Drug and Alcohol <br />Clearinghouse. Visit https://clearinghouse.fmcsa.dot.gov/register and click Go to login.gov. <br /> <br /> <br />_____________________________________ ____________________________________ <br />Signature of Applicant/Employee Signature of Witness <br /> <br /> <br />_________________________________ <br />Date <br /> <br /> <br /> <br />Drug Screening Refusal of Consent <br /> <br />I hereby refuse to submit to the drug and alcohol testing process. <br /> <br />I have seen a copy of the City’s Controlled Substance and Alcohol Testing for Commercial Drivers <br />(DOT) Policy and understand that, if I am an applicant, my refusal to submit to testing will subject me <br />to withdrawal of the City’s conditional offer of employment, and if I am an employee, my refusal to <br />submit to testing will subject me to disciplinary proceedings including, but not limited to, employment <br />discharge. <br /> <br /> <br />_____________________________________ ____________________________________ <br />Signature of Applicant/Employee Signature of Witness <br /> <br /> <br />_______________________________ <br />Date <br /> <br />If employee refuses to sign, indicate “Refused to sign”. <br /> <br /> <br />DATA PRIVACY NOTICE <br /> <br />The information collected pursuant to this policy is used to determine your eligibility for employment <br />and the performance of certain safety sensitive functions. You are not required to provide information <br />and submit to the tests, but your failure to do so will result in the City withdrawing a conditional job <br />offer or you may be disciplined (up to and including discharge) from employment, whichever may <br />apply. The results of the tests performed will be private data and will not be released to other <br />employers, governmental agencies, or persons without the written consent of the employee tested, <br />except as otherwise provided by regulation and law pursuant to a court order. Only those individuals <br />with a necessity to perform their functions under this policy will have access to the test results.