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t:aclrrnent D <br />RVjL1jDjMG-AN—VQ0 SUM <br />CENTMERINC <br />ALCOHOL <br />1, the undersigned, _.... , do hereby authorize the testing <br />of my body fluids for employment reasons and understand and agree that the results <br />of any such testan will he turned over to the Building and constructions Resource <br />Center, Inc. and, Et}ter that the testing procedures will he limited to tests for <br />prohibited and illegal drugs and controlled substances. <br />l understand that the results of these tests may be used for em loyanent and <br />discipli:naq reasons aat°ad hereby authorize the release of such information fron) <br />the laboratory and MRO. <br />l further certify that the urine specimen collected from me is arsine and not <br />adulterated oraltered in any manner. l have been advised that matters affecting <br />arse relative to the interpretation or application ofthe Drug Policy and subject <br />exclusively to the grievance and arbitration procedure under nay collective <br />bargaining agreement (if applicable). <br />Witness Signature of Applicant/Employee <br />Date Employee's Social Security Number <br />Time Employee's Telephone Number <br />Notary Public Employee's Address <br />Commission Expires City <br />Official Seal State &Zip Code <br />(Must be notarized if NO ID) <br />47 <br />