Drug and Alcohol-Free Workplace and Testing Policy Acknowledgement Form

I hereby state that I have received a copy of the Drug and Alcohol-Free Workplace and Testing Policy, dated Month day, year. I understand it is my responsibility to read and comply with the policy, and I agree to follow the policy. I have been given an opportunity to ask any questions I have about the policy.

I hereby agree to submit to a test and to furnish a sample of my urine, breath, hair, and/or blood for analysis. I understand and agree that if I at any time refuse to submit to a test under FictionSoft policy, or if I otherwise fail to cooperate with the testing procedures, or if I violate the policy, I may be subject to immediate termination or the withdrawal of a conditional job offer. I further authorize and give full permission to have the company and/or its physician send the specimen or specimens collected to a laboratory for a screening test for the presence of any prohibited substances, and for the laboratory or other testing facility to release any and all documentation relating to such test to the company and/or to any governmental entity involved in a legal proceeding or investigation connected with the test. Finally, I authorize the company to disclose any documentation relating to such test to any governmental entity involved in a legal proceeding or investigation connected with the test.

I agree to hold harmless the company, its managers, employees, officers, directors, shareholders, and physicians. I agree not sue or hold responsible such parties for any alleged harm to me that might result from such testing, including loss of employment or any other kind of adverse job action that might arise as a result of the test. I will further hold harmless the company, its managersmanager, employees, officers, directors, shareholders, and physicians for any alleged harm to me that might result from the inadvertent release or use of information or documentation relating to the test.

In addition to random and periodic testing, I understand that the company may require a test under this policy whenever I am involved in an on-the-job accident or injury under circumstances that suggest possible involvement or influence of drugs or alcohol in the accident or injury event.

Signature ________________________________________ Date __________________

Name (Printed) ___________________________________