CONSENT AND RELEASE FOR DRUG AND ALCOHOL
I, Applicant, understand that pursuant to Company Name's Policy for a Drug and Alcohol-Free Workplace, I am being required to drug screening test.
I hereby consent to submit to urinalysis, breath, blood, and/or other tests as shall be determined by Company Name for the purpose of determining the use of illegal drugs.
I agree that Testing Laboratory, or an alternate company selected facility, may collect these specimens for these tests and may test them or forward them to a testing laboratory designated by the Company for analysis. I further agree to and hereby authorize the release of the results of said tests to the Company.
I understand that it is the current illegal use of drugs and/or abuse of alcohol that prohibits me from obtaining employment with the Company.
I am unaware of any medical condition that would indicate that either the screen or physical examination might endanger my physical health.
I agree to hold harmless the Company and its agents (including the above named physician or clinic) from any liability arising in whole or part out of the collection of specimens, testing, and use of the information from said testing in connection with the Company's consideration of my continuing employment.
I agree that a reproduced copy of this consent and release form shall have the same force and effect as the original.
I have carefully read the foregoing and fully understand its contents. I acknowledge that my signing of this consent and release form is a voluntary act on my part and that I have not been coerced into signing this document by anyone.
APPLICANT NAME (PRINTED): Applicant Name
SOCIAL SECURITY NUMBER or UID: SSN
WITNESS NAME (PRINTED): Witness Name