Company Name: Text field
Applicant Name: Client first name Client middle name Client last name
I hereby consent, upon the request of Firm Foundation Ministries staff, to furnish a sample of my urine, breath and/or blood for analysis for a drug and alcohol test. I am fully aware that the results of this test will be retained by firm Foundations and will become part of my record.
I agree to having authorized personnel (l.e. Director of Operations, City Lead, House Lead and/or assigned Mentor) monitor me during the process of providing the urine sample.
I understand that if at any time I refuse to submit to a drug or alcohol test, or if I otherwise fail to cooperate with the testing procedures, it will count as a failed test and discipline action may be taken.
Signature
Signature of Applicant
Date:Date
Company Representative/ Title Text field