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ill F 0%m l I I l dl1:- AI;I1 1 102 i <br />Vill. Appendix A - Acknowledgemenumeceipt 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 co of the Plan has been made available to me and that <br />misuse. <br />Signed,thisthe day <br />Employee Name (Please Print) <br />Employee Signature <br />Premium Concrete services, Inc.- PHMSA DRUGlALCOHOL. PLAN 38 <br />(�' IJATIGMAL (:GMPLIANCE Mr1NAGf:MENi SERVICE, IFIG, (FILMS) %01t (ul iafo )f)21i. fne IJCMS mail is <br />Ifie sdbiacr of n Ieglslerod coRyr7glll anll is prol�cletl blcoRYd�llll laVls In Ilse U.S. and olsmMere. All riglfls <br />e.ervnd. <br />