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VIII. Appendix A - Acknowledgement/Receipt Form <br />acknowlegeT y signinq this form that my full compliance with the Anti -Drug and Alcohol Misuse <br />Prevention Plan (the "01an111 and DOT drug and alcohol regulation , duirements is a condition of my <br />initial and continued emplovment with the Company. I understand and agree that I may be discharged <br />or otherwise disciplined for anv 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 />also acknowledge by signinq this form that a copy of the Plan has been made available to me and that <br />I have read and understand the requirements of the Companv and DOT drug and alcohol program I have <br />also been provided with informational materials on the dangers and problems of drug abuse and alcohol <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 />':-J NATIONAL COMPLIANCE MANAGEMENt SERVICE, It,IG. (NCNIS)'2011 (update 20217. Th¢ �ICMS plan is <br />ido subJec( ofa reyistered copyright antl is proioclotl by copyright Imes in the U S. antl elsswliere. All rights <br />rese,ved_ <br />