If you are offered and accept employment with _____________ (hereinafter referred to as Company), you will be working with and around machinery and equipment that can cause injury to yourself and others. In the interest of safety, you will be required to take and pass a urine test for drug and/or alcohol use. This test is a standard part of the application for employment in the position for which you are applying with said Company.
My signature below signifies that I, ____________, have been fully informed by my potential employer of the reason for this urine test for drug and/or alcohol. I understand what I am being tested for, the procedure involved, and do hereby freely give my consent. I also understand that the results of this test will be sent to my potential employer and become part of my personnel record. If this test is positive, and for this reason I am not hired, I understand that I will be given the opportunity to explain the results of this test.
I authorise these test results to be released to the above Company.