I, ___________________________________________, understand that I have received an offer of employment dated ____________________ with [Company Name] that is contingent upon receipt of the results of a physical examination designed solely to determine my physical fitness to perform the duties of the position that I have been offered.
Accordingly, I voluntarily consent to a physical examination conducted at the request of and paid for by [Company Name]. I understand that I will receive a copy of the written examination and that I may also provide the examiner with additional information related to my ability to perform the duties of the position. I understand that I may ask questions of the examiner and may also stop the examination at any time.
I understand that if I fail to complete the examination or do not authorize the results to be released to [Company Name] within two calendar weeks (14 days) of the date of the conditional job offer, the job offer will be withdrawn.
Employee name (printed): _____________________________________________
Employee signature: _______________________________ Date: ______________
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