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<br />e <br /> <br />NOTICE TO EMPLOYER: If you have a Drug-Free Workplace Program established and maintained In <br />accordance with Florida law, and you would like 10 apply for the 5.~ premium credit that Is available, <br />please complele this fonn and forward It to your Insurer. Re-cer1lf1callon Is required annually. <br /> <br />APPLICA TION FOR DRUG-FREE WORKPLACE PREMIUM CREDIT PROGRAM <br /> <br />Name of Employer. <br /> <br />Tnfe.f"t1a11Ortal Gevl e tn..1 <br />.;J./~Jo~ <br />, <br /> <br />GH'\~rb. XYlc, <br />, <br /> <br />Dale Program Implemented <br /> <br />Tesling: <br />Procedures for drug testing have been established and/or drug lesling has been conducted In the loIlowing <br />areas: <br /> <br />[8""'Job apphcant <br />Q--Reasonable suspicion <br /> <br />a Routine fitness lor duty <br />1Wf011ow.up testing to <br />Employee Assistance Program <br /> <br />Nollce of Employer's Drug Tesllng Polley: <br /> <br />ijf'topy 10 all employees prior to lesting <br />[!yposted on employer's premises <br />lB"Copy 10 Job applicants prior to Ie sting <br />rtrGeneral notice given 60 days prior 10 testing <br /> <br />~how notice of drug testing on vacancy <br />announcements <br />l4"topies available in personnel office Of <br />other suitable locations <br />o No notice required because the <br />employer had a drug tesllng program <br />In place prior to July 1, 1990 <br /> <br />Education: <br /> <br />~esource file on providers <br />~mployee Assistance Program <br />~Educallon <br /> <br />Name of Medical Review officeJc::tI I ~ <br /> <br />Ij{Ih'~ Nt.1wcrK - D . <br /> <br /> <br />'is,/- . 3Y I. ZS z.S" <br /> <br />t <br /> <br />A. Name 01 approved Agency lor Health Care Administration Lab or United Slates Depa ent of Heallh and <br />Human Services Certified Laboratory: ^. 7) <br />~t.s T i~jVlos.fic oS, <br /> <br />B. Phone No.: (~OO ) ~11- 14gL{ <br />C. Address: 3/1S fft,s,df-rl.ftdl P(, Aft"n~ GJJ 3D~'lO ---- <br />Your certificallon is subjecllO physical vepficalion by the insurer. Your policy is subjecllo addillonal premium lor <br />reimbursemenl 01 premium credit. and canceUetion provisions 01 the policy il illS determined Ihal you misrepresenled your <br />compliance Wllll Florida law Any person "tlo kno,.,;ngly and Wllh IOlenllo injure. defraud. or deceive any ,nsurer files a <br />slatemanl 01 clam or an apphcalton conlaining any false. .ncomplete, Zr ISlead''''9 Informalio 5 gUllly of a felony of the <br />third degree . / -- <br />tmerM-H~1 ~ dn~, _ fE ~LO -7. <br />Employ., Name .rh~ / Dale ~- 0 ,iOwnor Sogn'lurp;.- <br />yfCL t:'~,d~141 O~ ~(,J;~'lS <br /> <br /> <br /> <br />o :zoo.. N.Uon,' Co~ncU on Com~n..Uon INuflnct, Inc. <br /> <br />-- <br />