Opening of Applications - 2024 Water Works Utility Service Line Repair Program - Bob Frame

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�T _� ACHM IEN T Ill I 4 � •�w�. � is o: i Trades s (M Ali Sl° I ) kI: 'ti!, r J II:Uilt- Marti apant Insu'u CTIOu1S: This form must be presented at the time of your drug and/or alcohol test. All blank spaces below must be filled out and witnessed by the collector. I, the undersigned, , do hereby authorize the testing of my urine for employment reasons and understand and agree that the results of any such testing will be released to DISA/Midwest Toxicology Services, LLC and, further that the testing procedures will be limited to tests for prohibited and illegal drugs and controlled substances. I understand that the results of these tests may be used for employment and disciplinary reasons and hereby authorize the release of such information from the laboratory and MRO. I further certify that the uripe specimen collected fi•om me is mice and not adulterated or altered in any manner. I have been advised that matters affecting the relative to the interpretation or application'of the Drug Policy are subject exclusively to the grievance and arbitration procedure under my collective bargaining agreement (if applicable). Reason for Deadline to Your Signature: Social Security Number: Telephone Number: Mailing address: City, State &Zip Code: Witness: Flease check only one box. Check local jurisdiction that you are currently working in. Union Local: ❑ 136 ❑ 157 ❑ 166 ❑ 172 ❑ 440 ❑ contractor participant (not covered by collective bargaining agreement) Current employer: ❑ Not currently working Instructions to Collector: . FAX and then mail this form along with the MRO copy of the chain of custody to the MRO at 317/262-2222, 603 E.` Washington St., Suite 200, Indianapolis, IN 46204. If you have any questions, please contact DISA/Midwest Toxicology Services at 800/3584450 or 317/262-2200. After 5 pm, contact 317/941-1222 or 317/847-2309. -20-