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Opening of Applications - 2024 Sewer Insurance Lateral Repair Program - Bob Frame
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Opening of Applications - 2024 Sewer Insurance Lateral Repair Program - Bob Frame
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2/13/2024 2:59:50 PM
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2/13/2024 2:58:17 PM
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Board of Public Works
Document Type
Projects
Document Date
2/13/2024
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1VIechanical Contractors t�ssoc. of Indiana/Indiana State Pipe <br />Trades (1VICAUISPT) <br />PARTICIPANT CONSENT FORM AND TESTING AUTHORIZATION FORM <br />PartlClparit lristrUCtIOriS: This form must be presented at the time of your drug and/or <br />alcohol test. All blank spaces below must be filled out and witnessed by the collector. <br />I, the undersigned, do hereby authorize the <br />testing of my mine for employment reasons and understand and agree that the results of any such <br />testing will be released to DISA/Midwest Toxicology Services, LLC and, further that the testing <br />procedures will be limited to tests for prohibited and illegal drugs and controlled substances. <br />I understand that the results of these tests may be used for employment and disciplinary reasons <br />and hereby authorize the release of such information from the laboratory and MRO. <br />I further certify that the urine specimen collected from me is mine and not adulterated or altered <br />in any manner. I have been advised that matters affecting me relative to the interpretation or <br />applicatiom'of the Drug Policy are subject exclusively to the grievance and arbitration procedure <br />under my collective bargaining agreement (if applicable). <br />Reason for <br />Your Signature <br />Deadline to <br />Social Security Number: Telephone Number: <br />Mailing address: <br />City, State &Zip Code: <br />Witness <br />Please check only one box. Check local jurisdiction that you are currently working in. <br />Union Local: ❑ 136 ❑ 157 ❑ 166 ❑ 172 ❑ 440 <br />❑ contractor participant (not covered by collective bargaining agreement) <br />Current employer: <br />❑ Not currently working <br />Instructions to Collector: <br />FAX and then mail this form along with the MRO copy of the chain of custody to the MRO at <br />317/262-2222, 603 E. Washington St., Suite 200, Indianapolis, IN 46204. If you have any <br />questions, please contact DISA/Midwest Toxicology Services at 800/358-8450 or 317/262-2200. <br />After 5 pm, contact 317/941-1222 or 317/847-2309. <br />-20- <br />
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