(YOUR COMPANY LETTERHEAD)

I do hereby certify that I have received, read and understand the (Your Company Name) Substance Abuse and Testing Policy, and have had the Drug-Free Workplace Program explained to me. I understand that if my performance indicates it is necessary, I will submit to a drug test. I also understand that failure to comply with a drug testing request or a positive result may lead to sanctions as laid out in the policy, including termination of employment.

Name:____________________________

Signature:_________________________

Date:_____________