I,
   (applicant name)

do hereby agree to submit to testing to be performed by:

(laboratory name/address)

for detection of drugs and alcohol.

I give permission for test results to be released to:

(company name)

I understand that the drug test results will remain confidential to the extent required by law and all records related to the test will be kept separately from my personnel file.

I understand that positive test results, refusal to be tested, or any attempt to affect the test results or test sample will result in withdrawal of my application for employment, withdrawal of any provisional employment offer I have received from:

(company name)

or termination of employment, depending on when results are received.

Signature

(checking the checkbox above is equivalent to a handwritten signature)