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Pre-Employment Urinalysis Consent Form

I understand that as required by the Federal Motor Carrier Safety Regulations, Title 49 United States Code of Federal Regulations, Section 391.103 and company policy, all prospective drivers must submit to a controlled substances test.

A urine sample will be collected and test for controlled substances.

I also understand that if I test positive for use of controlled substances, I am not medically qualified to operate a commercial motor vehicle.

The results of the drug test will be maintained by the Medical Review Officer for the company who will report whether the test results were negative or positive to the motor carrier. The results will not be released to any additional parties without my written authorization.

I hereby agree to submit to a drug screen urinalysis.

            _____________________________       ___________________

                                                Print Applicant’s Name                                                                            Date


                                                Applicant’s Signature

I hereby authorize you to release my Drug Screen Results to:
Attention: Sharon
137 Damon Rd, Suite B
Northampton, MA 01060-1819

1 800 331- 6880

Please fax results to: 1-413-587-5020      

            ______________________________     __________________

                 Applicant’s Signature                                                                              Date

                                                                                                                                                                                                 FOR FURTHER INFORMATION CONTACT:
1 800 331-6880