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<br />e <br /> <br />NOTICE TO EMPLOYER: If you have a Drug-Free Worltplace Program established and maintained In <br />accordance with Florida law, and you would like to apply for the 5.~ premium credit that is available, <br />please complete this fonn and forward lito your Insurer. Re-cer1lf1catlon Is requIred annually. <br /> <br />APPLICA TION FOR DRUG-FREE WORKPLACE PREMIUM CREDIT PROGRAM <br /> <br />Name of Employer. <br /> <br />~M <br /> <br />It1V~S"T~~, LV___ <br />.;J./~Jo~ <br />, <br /> <br />Date Program Implemented: <br /> <br />Testing: <br />Procedures for drug testing have been established andlor drug testing has been conducted in the lollowing <br />areas: <br /> <br />[8""'JOb applicant <br />Q--Reasonable suspicion <br /> <br />a Routine fitness lor duty <br />lWfollow-up testing to <br />Employee Assistance Program <br /> <br />NOllce of Employer's Drug Testing Polley: <br />ijf'topy to all employees prior 10 testing <br />[!yposted on employer's premises <br />ra--Copy to job applicants prior to Ie sting <br />!tr'General notice given 60 days prior to teshng <br /> <br />~how notice 01 drug Ie sting on vacancy <br />announcements <br />l4'toples available in personnel office Of <br />other suitable locations <br />o No notice required because the <br />employer had a drug testmg program <br />In place prior to July 1. 1990 <br /> <br />Education: <br /> <br />[J"'Resource file on providers <br />i;l--€mpJoyee Assistance Program <br />~Educatlon <br /> <br />Name of Medical Review officeJ oh I ~ <br /> <br />liClh'~ Ne.fwcrk - D . <br /> <br /> <br />qsy.. 31./ I. ZS zS- <br /> <br />e <br /> <br />A. Name 01 approved Agency lor Health Care Administration Lab or United States Depa ent of Health and <br />Human Services Certified Laboratory: ^ /'\, L' <br />~l'.s T .~/"jV10s.nc: S <br /> <br />B. Phone No.: (~OO) S?11-14g'-{ <br />C. Address: 3/1S fft'SIdf"(\-fidl Dr At1An'*". GA 3D"04fO ___ <br />Your cen,ficallon is SubjeCllo pnysical veflllcalion by ttle insurer. Your policy is subjeclto addilional premium for <br />reimbursement of premium credll, and cancellahon provisions of Ihe policy " ills determined Ihat you misrepresenled your <br />comphance w,lh Florida law Any person who knowingly and WIlli .nlentlo injure. delraud. or deceive any ,nsurer files a <br />slalemenl of cIa om or an apphcaloon conta,ning any false. 'ncomPlele'2r "leading .nlormaloo guilty 0' a felo~nY ollhe <br />Ihl(ddegre.. A -,,,, <br />-LfAA .Ii\\/~ VY2.6.. L-L-"--=- _ l"E. ,.M;)LJ) -"1 . <br />EmpIOYe1 Name ' Dale -- 0 ,/Owner Sognalur~ <br />J4c~ fi'~~(>K/ nF ~(-J;I1tS <br /> <br /> <br />01) 20O<C N.lIonaC Council 011 Com~n"UOf'lIl\f"'''nc'. fnc. <br /> <br />e <br />