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Chawanakee USD  |  E  4112.41, 4212.41,4312.41  Personnel

Pre-Employment Drug/Alcohol 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)

CHAWANAKEE UNIFIED SCHOOL DISTRICT

North Fork, California