Drug and Alcohol Verification Form

Please provide the following information and fax your company authorization form signed by the driver to 404-675-1964 or email to mnewman@premiertransportation.

Please provide your contact information:

First Name

Last Name

Title

Organization

Work Phone

FAX

E-mail

Please provide driver information below:

First Name

Last Name

SSN Number

Starting Date

-- mm/dd/yy
Ending Date

-- mm/dd/yy

Driver License #

Preferred method of return verification:

Fax         Email