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Waugh ESD |  E  4212.41  Personnel

Employee Drug Testing   

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Consent For Drug/Alcohol Test

Name: ______________________ Social Security Number: ____________________

Home Address: __________________________________________

Home Telephone: ________________________________________

Applicant for the position of _______________________________________________

I hereby consent and agree to give a specimen of my (urine or blood)_ to the examining physician, to be used to detect the presence of drugs, alcohol or medications in my body. I further consent and agree that upon request by (district) , the laboratory results of any tests performed on this specimen shall be furnished to the district by the laboratory. I have read and understand the foregoing statement and have answered all questions truthfully.

____________________________________

(applicant signature)

____________________________________

(date)

____________________________________

(witness signature)

____________________________________

(title)

____________________________________

(telephone number)

WAUGH SCHOOL DISTRICT

Petaluma, California