Application Form

Please list three professional references.

I certify that my answers are true and complete to the best of my knowledge.

If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release.

hereby consent to provide a or, specimen and/of Mood, hair or saliva specimens for the purpose of testing for the presence of prohibit. drugs. I understand Nat the test results will be sent to the Medical Review Officer and/or employer's designated representative who is responsible Mr the company's drug testing program, unless prohibited by law. I understand Mat refusing to provide or tampering with the urine/hair specimen ox providing false information on a specimen's chain of custody form, may constitute grounds for the termination of employment. I understand that failure to pass the drug test may result in disciplinary action up to and including termination, and that I may be required to participate in a mandatory rehabilitation treatment program (if offered by employer) as a condition of continued employment should my drug test results indicate drug abuse. I consent freely and voluntarily to the company's request for a specimen. I hereby release and hold harmless the company and its employees and agents from any liability whatsoever arising from this request to furnish my specimens and the testing of my specimens. I understand that all information derived from this test will be kept confidential and released only to my employer's designated representative. I also understand a documented chain of specimen custody exists to ensure the Identity and Integrity of my specimens throughout this collection and testing process.

hereby consent to provide a blood, breath, urine, or saliva specimens for the purpose of testing for the presence of alcohol. I understand that this information will be sent to my employer's designated representative who is responsible for the company's drug/alcohol program. I understand that the failure to pass the test may result in disciplinary action up to and including termination, and that I may be required to participate in a mandatory rehabilitation treatment program (if offered by employer) as a condition of my continued employment should my drug/alcohol test indicate abuse.

I understand that either parent/guardian and/or minor will be contacted concerning a positive drug or alcohol result.

I hereby authorize American Asphalt Sealing, as well as law enforcement agencies and/or private background check organisations to conduct a background check as a part of its hiring process. The information, in part or in whole will Sc provided to American Asphalt Sealing In the form of a report.

I authorize and consent to the retrieval of information that may include but is not limited to organizations, federal, state, or county level agencies, insurance sources, driving and criminal history.

The information contained in this application is correct to the best of my knowledge. I acknowledge that any answers or information be found Incorrect or omitted will be just cause for termination of employment.