Pre-Employment and Employee Health Services Request Company Name*Ordering Person Name* First Last Client ID*Applicant Name First Last Applicant Date of Birth Date Format: MM slash DD slash YYYY Applicant Social Security NumberEmail Address of Applicant* Required Services* Drug Screening Test Criminal History Report Driver's History Report (DMV) - must include Driver's License as proof of ID Office of the Inspector General (OIG) Exclusions List Sex Offender Registry Social Security Trace / ID Verification CommentsI, the Applicant, understand that pursuant to the Company’s Policy for a Drug and Alcohol-Free Workplace, and background compliance requirements I am being required to submit to. I hereby consent to submit to urinalysis, blood, and/or other tests as shall be determined by the company for the purpose of determining the use of illegal drugs. I also consent to the submission of required personal information to my potential employer for submitting a request for a comprehensive account of my criminal history, driving record and/ or presence in the Office of the Inspector General (OIG) exclusions list, as shall be determined by the Company and as indicated above to be used solely for the purpose of determining my eligibility for employment, as outlined in the companies Policies and Procedures. I agree that a testing method and records retrieval method of the Company’s choice, may collect these specimens for these tests and may test them or forward them to a testing laboratory designated by the company for analysis. I further agree to and hereby authorize the release of the results of said tests to the Company. I also hereby authorize the company to send the required information to the necessary provider to acquire my criminal history record, driving record and compare to the OIG exclusions list for the sole purpose of acquiring relevant reports to determine my eligibility for employment as outlined in the company’s Policies and Procedures. I understand that illegal use of drugs and/or abuse of alcohol that prohibits me from obtaining employment with the Company. I also understand that certain information contained in the acquired reports may prohibit me from obtaining employment with the company as outlined in the Company’s Policy and Procedures and/ or as determined by Federal, State and local laws and regulations. I am unaware of any medical condition that would indicate that either the screen or physical examination might endanger my physical health. Please indicate all medications currently prescribed: • • • • I agree to hold harmless the Company and its agents (including the above-named physician or clinic) from any liability arising in whole or part out of the collection of specimens, testing, and use of the information from said testing in connection with the Company's consideration of my continuing employment. I agree that a reproduced copy of this consent and release form shall have the same force and effect as the original. I have carefully read the foregoing and fully understand its contents. I acknowledge that my signing of this consent and release form is a voluntary act on my part and that I have not been coerced into signing this document by anyone.Signature First Last Date Date Format: MM slash DD slash YYYY Witness Name First Last Specimen temperature within range (90-100 F)?Yes or NoTimeNameThis field is for validation purposes and should be left unchanged.