Opening of Bids - Demolition of Rabbi Shulman Apartments Proj No 125-014 - Pitsch Companies

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Pitsch Companies Certificate of Receipt for Company Policy On Employment +® The employer shall ensure that each covered employee/applicant is required to sign a statement certifying that he or she has received educational materials that explain DOT drug and alcohol testing requirements (and the employer's policies and procedures with respect to meeting these requirements) before performing safety -sensitive duties for the employer. The employer shall maintain the original of the signed certificate and may provide a copy of the certificate to the employee/applicant. EMPLOYEE/APPLICANT NOTICE: READ BEFORE YOU SIGN The DOT requires the Company to provide covered employees/applicants (and representatives of employee organizations) with educational materials that explain DOT regulations regarding drug and alcohol use and abuse, Company policies and procedures for meeting those regulations, and other information and training concerning the effects of alcohol and controlled substances use. The DOT also requires you to sign a receipt certifying that you have received these materials. Refusal to sign this form upon receipt of the materials will be grounds for discharge. By signing this receipt you agree that you have received and read and are responsible to understand the Company policy, DOT regulations regarding alcohol and drug use testing, and all Company training materials included with or referenced in this material. Any questions you have regarding the above materials or this certification form may be addressed to the Designated Employer Representative (DER). See page 3 of your copy of the Company's Combined Drug/Alcohol Substance Abuse Policy for the Name, Address, and Phone Number of the DER. By signing this receipt, you are agreeing that your questions have been answered to your satisfaction. The original of this form will be retained by the Company in a separate file along with other Company records maintained for the Company's DOT drug and alcohol testing programs. Your copy of this receipt will be found in the back of your copy of the Company's Combined Drug/Alcohol Substance Abuse Policy. CERTIFICATION by Employee/Applicant: 1 certify that I have received a copy of the Company Substance Abuse Policy and other educational and training materials which the Company is required to provide as explained in the above notice, and that I have a record of the Name, Address, and Phone Number of the Company's current DER on page 3 of my copy of the Policy. Furthermore, I agree that I am responsible for reading, understanding and obeying all current Company policies and DOT regulations regarding alcohol and drug use testing and all future changes in or additions to those policies and regulations as they are adopted by the Company. I further understand and agree that I may be subject to disciplinary action and other liability for violating DOT regulations and/or Company policies. Prior to signing this Receipt, I read it carefully and any questions I had regarding the above materials and/or this form have been answered to my satisfaction. NOTE. 49 CFR 386 Appx B(a)(1-3) provides for penalties of (variously) $1,000/day (failure to prepare), $10,000 (knowing falsification of records), and $11,000 per (non-recordkeeping) violation of 49 GFR parts 382, 385, and 390-99 ($1,000/day provisions also apply to part 40). Employee Signature Print Name Witness Signature Print Name Date: Date: / 1 2020 Drug Screens Plus, All Rights Reserved. (37) FMCSA 20200101 266