I, __________________ [applicant name], agree to submit to testing to be performed by [facility/laboratory name] for the detection of drugs and/or alcohol as required for employment consideration with [Company Name]. I give permission for test results to be released to [Company Name].
I understand that [where allowed by state law] 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 and/or withdrawal of any provisional employment offer I have received from [Company Name].
I agree to hold harmless and release from all claims [Company Name] and its agents (including the above-named facility/laboratory) from any liability arising in whole or part out of the collection of specimens, testing and the appropriate use of the information from such testing.
Applicant name: ____________________________
Signature:_________________________________ Date:_______________
Witnessed by:______________________________ Date:_______________
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