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Trades F L' 'CAi ID _ h <br />��I QIlC9)pail� 1ffiS$ t'aA�$lOHS: This form must be presented at the time of your drug and/o <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 urine 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 mice and not adulterated or altered <br />in any manner. I have been advised that matters affecting me relative to the interpretation or <br />applicatiotr'of the Drug Policy are subject exclusively to the grievance and arbitration procedure <br />wider my collective bargaining agreement (if applicable). <br />Reason for <br />Deadline to <br />Yoor Signattu•e: <br />Social Security Number: Telephone Number: <br />Mailing address: <br />City, State & Zip Code: <br />Witness:, <br />Date: Time: <br />Please check only one box. Check local jurisdiction that you are currently working in. <br />Union Local: ❑ 136 ❑ 157 ❑ 166 Cl 172 0 440 <br />0 contractor participant (not covered by collective bargaining agreement) <br />Current employer: <br />❑ Not currently wokhng <br />Lnstructions to Collector: <br />FAX and then mail this form along with the MRO copy of the chflin 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 800/3584450 or 317/262-2200. <br />After 5 pm, contact 317/9414222 or 317/847-2309. <br />-20- <br />