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y�u0 1 ,()21 <br />V111. Mnendix A - Acknowledciement/Recei tp rorm <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 />n the DOT drug and alcohol regulatory requirements. <br />also acknowledge, by signing 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 Company 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, this the 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, INC. (NCMS)10t � (u�tlata 2U21J.'rhe IVCMS plan is <br />the subjau ofa registered wpyriyht and is proledotl by wpyfight laves In the U S. antl eIsS�Mere. All (glils <br />ccrved. <br />