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1 fter u 7 e-e. n n f ii)21 <br />Vill. Appendix A = AcknowledaemenumecewL Form <br />I acknowledge by signing this form that my full compliance with the Anti -Drug and Alcohol Misuse <br />Prevention Plan (the "Plan") and DOT drug and alcohol regulation requirements is a condition of my <br />initial and continued employment with the Company I understand and agree that I may be discharged <br />or otherwise disciplined for any drug and/or alcohol violation committed by me as cited in the Plan and/or <br />in the DOT drug and alcohol regulatory requirements. <br />I also acknowledge by signing this form that a copy of the Plan has been made available to me and that <br />misuse. <br />Signed,thisthe day of , 20 <br />Employee Name (Please Print) <br />Employee Signature <br />Premium Concrete Services, Inc.- PHMSA DRUG/ALCOHOL PLAN 38 <br />S1 �JATIONAL GI�MPLIANCE MANAGEMENT SERVICE, I�IG. (NCMSJ L011 (uptle�e 2021i. ire IVCMS p��n is <br />iho s�ibjoct o(a registered wpyngh� antl is prutaclaU by wpyngh� laves in Ilse U.S. and elseevhare. Ail rly�ls <br />e smed <br />