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The purpose of this consent is to explain the resu113 of my t1rug test, wnen relevant, :n <br />or leb..l proceedinb. This consent shall be valid so long as any administrative, civil or legal proceeuing resat : -g [o <br />cR7,.te,...cnt t., Wn:�n t o- u party continues. I abree that Firs,Service Residential and its agents shall not oe nefa dame <br />i.-. ory mu,,.t Cor pre. -:dins M.t flare requested as set fonh above. <br />I acknow,eege Mat executing oris Au&pj.�,t;e-.tn..t t Hay. the ribht to receive a copy of this <br />Authorization if I request one. <br />I understand I may ask--yuesdons about the testi. I understanu Mat tnis is a summary of rirstberviee <br />R=' ;t:..t'a Drub and Alcohol Abuse Policy and that the full Policy governs my Lesting. <br />eLr t r tc tcc.Auuvf% it n[3 FOturt_ CUn3IurR31gG l Hf': t Obsu3GE CONSEQUENCE5OF MY CHUICES; I <br />FREELY AN„ rvtrun IAscu.,1: <br />AGREE AND CONSENT TO BE TESTED UNDER Atop <br />ALECHUL AISU3t rULICV. <br />Dalt: <br />EMPLOYEE SIGNATURE <br />rMrLD Y rr'3 rttt tv I ED NAME <br />Date <br />MANAGEMENT REPRESENTATIVE SIGNATURE <br />A�s898_3 -1 <br />14j <br />