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<br />ACKNOWLEDGEMENT OF RECEIPT
<br />OF
<br />DOT DRUG AND ALCOHOL POLICY AND TESTING PROGRAM
<br />FOR
<br />WALSH & KELLY, INC.
<br />..... . .......
<br />I acknowledge that K have received a cop), of the DOT Drug and Alcohol Policy for WALSH so
<br />KELLY, INC,
<br />I understand that it is in), responsibility to read the policy in its entirety
<br />I understand that as an employee of WALSH & KELLY, INC, I araniquinal to abide by the
<br />rules and regulations established by [his policy, and that I am subjml to consequences if K violate
<br />the poliry.
<br />I understand that the policy may change to comply v,ilh federal and state laws, and that I may
<br />obtain a current copy offlo, policy at any time, dining busyness hours fi orn my employer's
<br />designated employe, representative (DER)
<br />I understand that if have any questions about this policy, or if need assistance or resources
<br />related to alcohol andlor drug -related issues or problems, I may take those questions and
<br />rin"IMS to my employer's DER,
<br />Idameof Emplopee (print ',u u aiginers
<br />Social Security No Date
<br />51—g.awrc of Supervisor or Dkr.R— - — — --------- ----------
<br />faseructions: D01'requires all DOT -covered employees to sign this acknowledgernmi form
<br />The original of this fierin will bu retained in Inc v ployec',, file in compliance with DOT
<br />regulations
<br />An employee who refuses to sign this acknowledgement form is disqualified from providing
<br />safety -sensitive function for WALSH & KELLY, INC
<br />SUBSTANCE ABUSE POLICY
<br />APPENDIX 3
<br />[, lAPPLICANTS FOR DOT -COVERED POS T16Ni
<br />I'l�!��Y.i lINFORMATION FOR...
<br />OR, ".!.m...... ... ...........................
<br />I
<br />Federal law requires applicaras to indicate whether they have previously rid`tei,cl 10 be tested or
<br />received a pastl.ive test result on any prcempkayancnt test far anp other 116"[' employer Please
<br />provide this information below, II is a federal offense to falat£y pail inforznation.
<br />I Gave NOT tested positive an a preempinyment drug test for any oprcr D<}T employer
<br />in I.he past trvo years, nor have 1 refused to Tic tested. (irr.,please sign below, and
<br />ramplcle the remuinder of this form.}
<br />D Yes, l tested positive (or I refused to be tested) on a pre employnnau drug test r—nod-
<br />DOT npl.y.r in the p..,l two y, n,', (ifs., lar...,nitc helaw, otrd do not va.nran)
<br />Sigrirt—rAppli,anl Done
<br />finch applicant f.r a DO"I'covered position at Emplcyer, alter being nol.ified IiYat he(she aitl be
<br />alpercd ajoh. must be drug tested., in arcordancr, a ipr Federal eeynalalions 49CFRPurl 392 If the
<br />test result is positive, or if the apptie.1 refuses to 'inarat I.. pre -employment test diaJob hTcr
<br />vnil be o,othbawrs
<br />We inuel have a negative test result in our ilk before we can request or allow in employee to
<br />provide safety -sensitive fineelm for us
<br />The .,.,it of the in hid s';ox.u.@ test and the -ol.ocni,) met will be paid by (Cornpany
<br />Every applicant who pro, ides a positive lest result a ill have an oppeounny W speak with a
<br />Medical Review Off— ab-nan, .—L use.fti—criplici. and r—in—unk,a drugs that
<br />inighl -phar, the p.sni'e test ne.11
<br />An applicant whose test result is positire maw. a ithio ir2 boors, neq,1 at In.,11- -n
<br />"isv.sv The re lost will be e.adbieled .. the %ann. sample ., was provided Far ffie apilml lea,
<br />and inusl be conducted by a different testing labecapin, that raccle [lie 'eq,oresionle of
<br />—nitration DOT',, lesnalt —jai—ents
<br />I he,, not tested poslike (a, refused to be anaid) on a DOT pro —pk,yr.rat drug teat, at any
<br />ture in the inc,ms two yearn
<br />Mysignature hot.,, —, that I have read this inamnial.., that I have had in. appralarilyb.
<br />roviow. copy of(c..p..), N—) drug and alcohol analog policy, and thin if .m aff—d a
<br />proW.., I cce-.1 to bring Icsted for drugs a, a -rdih- ofaraployrnew
<br />Signature or Applicant Date
<br />Agreement
<br />is
<br />BY AND BETWEEN
<br />INDIANA CONSTRUCTORS, INC
<br />LABOR RELATION DIVISION
<br />And
<br />LOCAL UNIONS
<br />OF
<br />LABORERS'INTERNATIONAL
<br />UNION OF NORTH AMERICA
<br />STATE OF INDIANA
<br />DISTRICT COUNCIL
<br />MARCH 1, 2012
<br />Through
<br />MARCH 31,2017
<br />61 64
<br />
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