Fill and Sign the Formauth for Physical Exam

Basic form © James R. McDade (ver 05-30-06) 209-667-2300 CO NDIT IO NAL J O B O FFE R Em plo yers u se t h is f o rm t o m ake a c o ndit io nal o ffe r o f e m plo ym en t c o ntin gen t o n t h e em plo ye e p assin g a p hys ic al e xam a n d/o r d ru g t e s tin g. (D ele te t h is n ote p rio r t o u se.)I u nders ta nd t h at t h e o ffe r o f e m plo ym ent e xte nded t o m e b y _ ______________________ (here in afte r " C om pany") is e xp re ssly c o ndit io nal o n m y s u bm it tin g t o a nd p assin g, t o C om pany's so le s a tis fa ctio n , a ll o f t h e f o llo w in g m ark e d t e sts : A p hysic a l f it n ess f o r d uty e xa m in atio n, in clu din g b ack e xa m in atio n A u rin e t e st f o r c o ntr o ll e d s u bsta nce s s cre enin g A u rin e o r b re ath t e st f o r a lc o hol s cre enin gI u nders ta nd t h at r e fu sa l t o t a ke a p hysic a l e xa m in atio n, r e fu sa l t o s u bm it a b lo od o r u rin e sam ple f o r t e stin g, o r r e fu sa l t o s ig n a n a uth oriz a tio n f o rm r e le asin g t h e t e st r e su lt s t o t h e Com pany m ay r e su lt in t h e C om pan y r e vo kin g it s o ffe r o f e m plo ym ent. [N ote : A ls o h ave t h e e m plo ye e sig n a n A uth o riz a tio n f o r R ele ase o f M edic a l I n fo rm atio n ( D ele te t h is n ote p rio r t o u se .) ]I a ls o u nders ta nd t h at t h e o ffe r o f e m plo ym ent is c o ndit io ned o n t h e f o llo w in g: My p assin g a b ackg ro un d in ve stig atio n Verif ic a tio n o f t h e v a lid it y a nd g ood s ta ndin g o f m y lic e nse s f o r _ _____________ My p assin g a s kills t e st f o r _ ____________________ Verif ic a tio n o f m y r e fe re nce s, e duca tio n, a nd o th er in fo rm atio n o n m y jo b a pplic a tio n Oth er: _ _ ____________ _____ ________________ _____________ ___________I u nders ta nd t h at if I a m a llo w ed t o b egin w ork p rio r t o t h e C om pany o bta in in g t h e t e st r e su lt s o r ve rif ic a tio n s, a nd if t h e t e st r e su lt s o r v e rif ic a tio ns a re n ot s a tis fa cto ry t o t h e C om pany, t h en I un ders ta nd t h a t m y e m plo ym ent m ay e nd a t t h e s o le d is cre tio n o f t h e C om pany. [N ote : It is a b ette r pr a ctic e t o o bta in t h e r e su lt s a nd v e rif ic a tio n p rio r t o a llo w in g a jo b a pplic a nt t o b egin w ork . ( D ele te t h is n ote p rio r t o u se .) ]_ _ _____ _______________ _______________ __________________________P ro sp e ctiv e E m plo ye e’s S ig natu re Date