PRE-EMPLOYMENT DRUG/ALCOHOL TESTING
CONSENT AND RELEASE FORM
I hereby consent to submit to a drug or alcohol test and to furnish a sample of my urine,
breath, and/or blood for analysis, as shall be determined by (Company Name)
__________________________________________ in order to meet with their policy
regarding the selection of applicants for employment.
I further authorize and give full permission to have the Company and/or its authorized
agents and physicians to send the specimen or specimens so collected to a laboratory
for a screening test for the presence of any prohibited substances under the policy, and
for the laboratory or other testing facility to release any and all documentation relating to
such test to the Company. 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 use of illegal drugs that would prohibit me from being
employed at this Company.
I further agree to hold harmless the Company and its agents and physicians 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
application of employment.
I further agree that a reproduced copy of this pre-employment 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:
Print Name: ____________________________ S.S.#: __________________
Signature: ____________________________ Date: ___________________
WITNESS:
Print Name: ___________________________
Signature: ____________________________