Consent of Release Form

Drug Free Workplace Program as an employee/applicant of:

Drug Free Workplace Program


as an employee/applicant of:


Company of Nevada, Inc. hereby acknowledge that the company’s policy requires me to submit a sample of my urine for chemical analysis.

I further understand that the purpose of this analysis is to determine or rule out the presence of any alcohol or controlled substances in my urine. It is also to determine if there is present any prescription drugs or non-prescription drugs in levels sufficient to place me “under the influence”, or otherwise “impair” my ability to perform my job.

I hereby freely and voluntarily consent to this request for a urine specimen and agree to participate in the testing program.

I hereby and herewith release the company, its employees, agents, contractors, workman’s compensation insurance carrier, and laboratory testing facility from any and all liability whatsoever arising from this request for a urine sample, from the testing of the urine sample, and from decisions made concerning my application for or continuation of employment based upon the results of the analysis.

I agree to cooperate in all aspects of the testing program. I understand that refusal to take this test or attempts to adulterate my urine sample shall result in either a denial of my application for employment, or if already employed, my termination from employment.

I further acknowledge that the company has provided me with an opportunity to ask questions related to its drug testing program and that all my inquiries have been answered.

Employee/Applicant Signature:______________________________________________________________________


Witness Signature:________________________________________________________________________________

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