I have applied for employment with [Company name] and as a condition of employment, I must be and I must remain drug-free. I understand and agree to undergo pre-employment substance screening. I understand that if my pre-employment test results are positive, my application will not be considered further.

I further understand that during the course of any employment with (Company name) I agree to be subject to periodic substance screening and if any test results are positive, my employment may be terminated.

I hereby authorize any physician, laboratory, hospital or medical professional engaged by [Company name] to conduct substance screening and to provide the results to [Company name], and further, that I release [Company name] and any person affiliated with [Company name] and any institution or person conducting the screening, from all liability in connection with the screening.

Applicant's signature:___________________________________________

Applicant's name: _____________________________________________

Date:______________________________________________________