I hereby consent to allow [facility name] to take a specimen of my hair, urine, or blood and submit it to a laboratory testing service for a pre-employment, random or reasonable suspicion drug test. I further consent to allow the laboratory testing service to make the results of the drug test available to [Company Name].
I understand that [where allowed by state law] positive test results, refusal to be tested or any attempt to affect the test results or test sample will result in withdrawal of my application for employment and/or withdrawal of any provisional employment offer I have received from [Company Name] or termination of employment, depending on when the results are received.
I agree to hold harmless and release from all claims [Company Name] and its agents (including the above-named facility) from any liability arising in whole or part out of the collection of specimens, testing and the appropriate use of the information from such testing.
Name: _________________________________
Signature: ______________________________ Date: _______________________
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