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JIQ <br />JOHNSON-DAVIS INC.. <br />604 NB1BRAh1 DRIVE <br />LANTANA, FLORIDA 33462.1664 <br />661.560-1170 FAX 661466-6252 <br />ClLC043067 - <br />EMPLOYEE/APPLICANT ACKNOWLEDGEMENT FORM <br />Read carefully; if you do not understand a question please ask. Initial each item then sign and date at <br />the bottom. <br />1. 1 have received and read the Company's current Drug Free Workplace Policy, including <br />the medications that may alter or affect a drug test (D177114). (Applicants only). <br />2. 1 understand that if I refuse to submit to a pre-employment drug test or refuse to <br />authorize the release of my drug test results that I will not be hired. (Applicants only). <br />3. 1 understand that total compliance with the Drug Free Workplace is a condition of <br />continued employment with this Company. <br />4. 1 received a list of local Employee Assistance Programs and Drug and Alcohol <br />Rehabilitation Programs (DFW-1). <br />5. I understand that if I refuse a reasonable suspicion drug or alcohol test, I will lose my <br />job and my unemployment benefits. 1 also understand that if 1 refuse to take a test that <br />was requested as a result of my involvement in a work-related accident, I will lose all of <br />my related workers' compensation benefits, if I am injured. <br />6. 1 understand if I am taking any medication that could affect my ability to perform my <br />duties, I must inform my supervisor immediately. (Employees Only). <br />7. 1 understand I have the right to challenge any positive test result and I understand that 1 <br />must notify the laboratory if I wish to challenge the test result. <br />8. I understand that the Company's Drug Free Workplace Policy does not constitute an <br />employment contract for term between the Company and me. <br />I have read, understood and initialed each above item and have voluntarily signed this form below. <br />Printed Narrie <br />Signature <br />Witness Name <br />Date <br />S.S.# <br />Date <br />