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SPECIFIC MEDICAL RELEASE <br />Now comes <br />who states that he/she is an <br />employee for Trisco Systems, Inc., located at 2000 Baty Road Lima, Ohio 45807. The <br />undersigned states that he/she was required to take a drug/alcohol test pursuant to his/her <br />condition of employment at Trisco Systems, Inc., and hereby releases to Trisco Systems, <br />Inc., any and all medical information relating to drug/alcohol test results based upon a <br />drug/alcohol test administered on the day of 520 <br />Further, the undersigned authorized the release of any medical information <br />concerning rehabilitation as a result of the drug test performed on the above referenced <br />date. Under no condition shall any other medical information unrelated to the drug testing <br />or the rehabilitation thereof, be released to Trisco Systems, Inc. <br />WITNESSES: <br />EMPLOYEE: <br />DATE: <br />