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SAFETY &HEALTH MANUAL <br />APPENDIX A-ACKNOWLEDGEMENT/RECEIPT FORM <br />ANTI -DRUG & ALCOHOL MISUSE PREVENTION PROGRAM <br />ACKNOWLEDGEMENT FORM <br />Acknowledgement: <br />I acknowledge, by signing this form, that my full compliance with the Anti -Drug and Alcohol Misuse Prevention Plan (the <br />"Plan") and DOT drug and alcohol regulation requirements is a condition of my initial and continued employment with the <br />Company. <br />I understand and agree that I may be discharged or otherwise disciplined for any drug and/or alcohol violation, <br />committed by me, as cited in the Plan and/or in the DOT drug and alcohol regulatory requirements. <br />I also acknowledge, by signing this form, that a copy of the Plan has been made available to me and that I have read and <br />understand the requirements of the Company and DOT drug and alcohol program. <br />I have also been provided with informational material on the dangers and problems of drug abuse and alcohol <br />misuse. <br />Print Name <br />Signature: <br />Date: <br />Trained by Name Trained by Signature: Date: <br />SECTION 42: Anti -Drug & Alcohol Misuse Prevention Plan Program I Page 38 of 49 <br />