Fillable Printable Refusal To Submit To A Federal Drug Or Alcohol Test

Refusal To Submit To A Federal Drug Or Alcohol Test

CDL-9 (01-08)

NORTH CAROLINA

DEPARTMENT OF TRANSPORTATION

DIVISION OF MOTOR VEHICLES

REFUSAL TO SUBMIT TO A FEDERAL DRUG OR ALCOHOL TEST

PURSUANT TO *G.S. 20-37.19(c) AND G.S. 20-396 THE UNDERSIGNED EMPLOYER

HEREBY NOTIFIES THE DIVISION OF MOTOR VEHICLES THAT THE INDIVIDUAL BELOW

REFUSED TO BE TESTED FOR DRUGS OR ALCOHOL AS REQUIRED BY FEDERAL

REGULATIONS.

*Do not include Pre-Employment Refusals

Attach confirmation from Testing Agency if applicable

Employee’s Name ______________________________________________________________

Driver License Number ________________ State ____ Social Security Number ____-___-_____

Employee’s Address ____________________________________________________________

Name of Employer ______________________________________________________________

Employer’s Address _____________________________________________________________

Telephone No. of Employer ( )_____________ Employer Contact Name __________________

Type of Company ( ) Commercial ( ) Transit Driver ( ) Government ( ) School Bus

Program

**Date of Refusal _________________________ **Type of Test Refused:  Alcohol  Drug

**Reason for Test:  Random  Reasonable Suspicion

 Post-Accident  Return to Duty  Follow-up

Send To: NC DMV

Commercial Drivers License Unit

3117 Mail Service Center

Raleigh, NC 27699-3117

Or Fax to: (919) 861-3302

(If faxed, mail the original to the above address)

* G.S. 20-37.19. Employer Responsibilities

Part 655 shall notify the Division of Motor Vehicles in writing within five business days following the employer’s

receipt of confirmation of a positive drug test. The notification shall include the driver’s name, address, drivers

license number, social security number, and results of the drug or alcohol test.

*G. S. 20-396. Unlawful Motor Carrier Operations

**THIS INFORMATION IS REQUIRED