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• CITY OF BATESVILLE <br /> 500 EAST MAIN <br /> BATESVILLE, ARKANSAS 72501 <br /> Phone 870-698-2400 <br /> Fax 870-698-2406 <br /> CONSENT TO DRUG AND ALCOHOL TEST <br /> I UNDERSTAND that according to the City of Batesville's Drug and Alcohol Free <br /> Workplace Policy, which I have read and understand, I may be required to undergo drug <br /> and alcohol testing procedures as a condition of employment. <br /> The PURPOSE of this testing is to determine the absence or presence of drugs or <br /> alcohol. <br /> I further UNDERSTAND that failure to consent to this drug and alcohol test will be <br /> considered as a reason for discharge. <br /> I CONSENT freely and voluntarily to any such drug and alcohol testing that the City <br /> Aconducts pursuant to its Drug and Alcohol Free Workplace Policy. <br /> t <br /> I UNDERSTAND that refusal to submit tQ any required test without a valid medical <br /> explanation may result in immediate disclUrge from my employment. Refusal to execute <br /> any required consent forms, refusal to cooperate regarding the collection of samples or <br /> submission or attempted submission of an adulterated or substituted sample shall be <br /> deemed refusal to submit to a required test. <br /> I UNDERSTAND that this information will be kept confidential and limited to "need to <br /> know"personnel authorized by the City. Beyond these individuals the results will not be <br /> released without my written consent or as otherwise required by law. <br /> Employee Date <br /> Witness Date <br /> 11 <br />