Momchilovich Drywall, LLC. (Company), has a vital interest in maintaining safe, healthful and efficient
working conditions for its employees and customers. Illegal drugs pose a serious threat to the health and safety
of the user and to others. Therefore, all applicants considered for employment at the Company may be required
to submit to a drug-screening test after receiving a conditional offer of employment. Employees will be tested
when reasonable cause exists to believe an employee may be using or under the influence of drugs or alcohol,
and in the other circumstances listed in the Company’s Drug and Alcohol Policy.
Please carefully read the following statements before signing this form:
I hereby give my consent to the Company to which I am applying for employment or by which I am employed,
to collect (or contract to collect) blood or urine samples from me to determine the presence or use of alcohol,
and/or controlled substances (including, without limitation, cocaine, marijuana, barbiturates, phencyclidine
(PCP), amphetamines, opiates and benzodiazepines). Further, I give my consent for the release of the test
results and other relevant medical information to the Company management and any physician(s) designated by
the Company for determination of my eligibility for employment.
I understand that if the results of the drug test are positive, I will be given an opportunity to discuss the positive
result and any reasonable explanation with a Medical Review Officer.
I understand that if a positive result is caused by medications prescribed by an accredited physician for the
treatment of a current condition, the Medical Review Officer may verify the circumstances of use with the
physician. I hereby authorize my prescribing physician to disclose such information as may be requested, and
will execute any additional consent as are necessary to obtain the release.
I understand that if positive test results are caused by drugs that are not part of a currently prescribed medical
treatment program, or if I refuse to sign this Authorization or cooperate fully in the specimen collection process,
or I switch or adulterate a test sample, I will not be hired, or if an employee, I will be subject to discipline up to
and including discharge. If not hired, I will not be eligible to apply for employment within the Company for
one year. I understand that if prescribed medication will adversely affect my ability to perform my job, my
application may be deferred, or rejected, or, if an employee, my employment may be suspended or terminated,
as appropriate. I release and discharge the Company, its Directors, Officers and agents from any claim or
liability arising from the tests described above, including the test process and procedures, the analysis and
disclosure of the results.