If you are offered and accept employment with___________________ (company), in the interest of safety for all concerned, you will be required to take a urine test for drug and/or alcohol use.
I,___________________________________, have been fully informed of the reason for this urine test for drug and/or alcohol (I understand what I am being tested for), the procedure involved, and do hereby freely give my consent. In addition, I understand that the results of this test will be forwarded to my potential employer and become part of my record.
If this test is positive, and for this reason I am not hired, I understand that I will be given the opportunity to explain the results of this test.
I hereby authorize these test results to be released