I, _______________________________, voluntarily, do hereby give my consent to the Company or a selected Laboratory to collect a urine or blood sample from me. If the Company collects the sample, I further give my consent to the Company to forward the sample to the Laboratory for its performance of appropriate tests thereon to identify the presence of drugs. I furthermore give the Laboratory my permission to release the results of such tests to the Company. I understand that any positive result or refusal to submit to testing may preclude my employment.

I realize my signature is necessary for me to be considered for employment with the Company. I understand the test results and other medical information will be released only to authorized Company personnel for appropriate consideration.

Name (Please Print – First, Middle, Last: _____________________________

Date: ________________________________

Signature: ________________________________

Employee Number (if known: ___________________

IMPORTANT NOTICE TO ALL ASSOCIATES

In compliance with the federal Drug-Free Workplace Act, all Company associates are hereby notified that the unlawful manufacture, transportation, promotion, distribution, dispensation, possession, purchase, use or sale of illegal drugs or alcoholic beverages by anyone while on Company business or premises is absolutely prohibited. This prohibition also covers illegal or prescription drugs which impair an associates’ ability to perform his/her job safely or properly. Any associate who violates this policy will be subject to disciplinary action, up to and including discharge, and will be reported to law enforcement agencies for possible criminal law action.

As a condition of employment an associate must:

1. abide by the terms of this policy; and
2. notify the Company of any conviction for a violation of a criminal drug statute occurring in the workplace no later than five (5) days after such conviction. Upon receiving such notice the Company will notify the appropriate federal authority.

The Company has established an Alcohol and Drug-Free Workplace Awareness Program to inform associates of:

1. the dangers of drug and alcohol abuse in the workplace;
2. the Company’s policy of maintaining a drug and alcohol-free workplace;
3. any available drug and alcohol counseling, rehabilitation and associate assistance programs; and
4. the penalties that may be imposed for drug or alcohol abuse violation.

Any associate convicted of violating a criminal drug statute in the workplace will be subject to disciplinary action or satisfactory participation in a drug abuse assistance program, as determined by the Company.

Please contact the Human Resources Department if you have any questions about our policy or this very important program. The Company wants to help anyone who needs assistance in this area.

ALL ASSOCIATES ARE ASKED TO ACKNOWLEDGE THAT THEY HAVE READ THE ABOVE POLICY AND AGREE TO ABIDE BY IT.

I have read, understand, and agree to comply with the Company’s Drug and Alcohol Policy.

(OVER) APPLICANT CONSENT FORM

I, _____________________________ voluntarily, do hereby give my consent to the company or a selected Laboratory to collect a urine or blood sample from me. If the Company collects the sample, I further give my consent to the Company to forward the sample to the Laboratory for its performance of appropriate tests thereon to identify the presence of drugs. I furthermore give the Laboratory my permission to release the results of such tests to the Company. I understand that any positive result or refusal to submit to testing may preclude my employment.

I realize my signature is necessary for me to be considered for employment with the Company. I understand that the test results and other medical information will be released only to authorized Company personnel for appropriate consideration.

I am currently taking prescription medicine or have taken prescription medicine with the last seven days. YES __________ NO __________

If yes, please identify the name(s) of the drug(s) and the length of time the drug(s) has been taken.

_______________________________________________

_______________________________________________

_______________________________________________

List below any non-prescription medication, such as aspirin, antacids, or other over-the-counter medicines taken in the last seven days.

_______________________________________________

_______________________________________________

_______________________________________________

Name (Please Print – First, Middle, Last) Date

Signature Employee Number (if known)

Employment Screening for Applicants

The Company requires all applicants who have been made a conditional offer of employment to undergo employment screening as part of the hiring process. Applicants will be required to complete an Application for Employment packet, which will include a Disclosure and Authorization form authorizing the Company to conduct a background check on the applicant.

The applicant must also be given a copy of the document titled “A Summary of Your Rights Under the Fair Credit Reporting Act.” The applicant must complete and sign both the Application for Employment and the Disclosure and Authorization form. These forms may also be provided electronically or via hard copy by a Company vendor. The Company will then request a background report from one of its approved third-party providers for employment screening.

If a Company associate checks an applicant’s references or employment history without using a third party, the background check authorization and the summary of rights forms do not need to be signed by the applicant.

The scope of the employment screening process will be determined by the Company and, at the Company’s discretion, may be narrowed or broadened depending on the particular circumstances of the case. Generally, employment screening will consist of the following elements:

• Social Security Number Trace: Confirming the applicant’s social security number and identifying relevant prior aliases and addresses to assist in the criminal conviction search;

• County Felony/Misdemeanor Criminal Conviction Search: Searching the appropriate court records relating to the applicant’s county of residence for evidence of felony and/or misdemeanor convictions in the previous seven (7)years (this time period may change in order to comply with applicable law);

• Education Confirmation: Confirmation (where available) of attendance, degree and graduation date from the institution where the applicant obtained his or her highest degree;

• Employment Confirmation: Confirmation (where available) of employment, position, pay, reason for leaving and eligibility for rehire from all employers who employed the applicant in the previous five (5) years (this time period may change in order to comply with applicable law); and

• Motor Vehicle Record: Reporting accidents, suspensions and violations from the state in which the applicant is a licensed driver for the maximum period provided by the Department of Motor Vehicles and for no less than the previous three (3) years.

Human Resources will evaluate the background report to ensure there are no discrepancies between the report and the information provided by the applicant on his or her Application for Employment or at any time during the hiring process. A candidate should not be hired if employment screening reveals information not reported or contrary to information that is self-reported during the hiring process (e.g., information reported on the employment application or in an interview), absent justification from the applicant that is acceptable to the Company.

If no inaccurate information is found and no omissions are evident, Human Resources will evaluate the background report to determine whether the valid information contained therein is consistent with the job being sought. In the event Human Resources discovers that an individual has a criminal conviction, Human Resources will consider the nature and gravity of the offense or offenses, the time that has passed since the conviction and/or completion of any related sentence, and the nature of the job assignment prior to making any employment decision.

Information released pursuant to the employment screening process will remain exclusively in the possession of Human Resources and will only be shared with individuals who have a business need to review the information to make employment decisions.