In case of emergency, notify:

Reference #2

Previous employer

Previous employer

I freely and coluntarily agree to submit to a urinalysis (drug screen) or breath test as part of my application for or continued employment. I understand that refusing to submit to the urinalysis or breath test may disqualify me from further consideration for employment or may result in termination.

I authorize the collector and laboratory to release information regarding the testing and the test results or statement showing that the test result was positive or negative to the company's designated official and MRO.

I understand that my alteration of this consent form, refusal to consent or to cooperate in the collection of urine specimens or my refusal to authorize the release of the results to the company will be grounds for termination.

I understand that a positive test result is grounds for termination or being excluded from employment consideration.

I further understand that:

1. All urine specimens will be tested for signs of alteration or dilution.
2. Tampering with specimens or intentionally using any means to conceal drug or alcohol use is strictly prohibited.
3. Evidence of specimen tampering may result in immediate termination or revocation of any offer of employment.
4. Specimens showing signs of dilution may not be acceptable and may result in re-testing.

Notification Regarding Testing Concerns

Applications and employees are required to immediately mortify the Company Resident of there is an unusual occurrence during the collection process that the employee (or potential employee) felt may jeopardize the credibility or accuracy of the test.

I have read and understand the above statements and consent to the collection and testing of the urine or breath specimen.
I agree that a Photostat copy of this authorization is as valid and effective as the original at any time hereafter, irrespective of the date thereof.
authorize TILCO Vanguard Inc. to use any photographs, which might be taken throughout employment, to be used for advertising purposes.
I have read n full and understand the above statements and conditions of employment.