405 Briarwood Drive Suite 107 – D
Jackson, MS 39206
PRE-EMPLOYMENT DRUG/ALCOHOL TESTING AND BACKGROUND CHECK
CONSENT AND RELEASE FORM
I hereby consent to submit to a background check and drug and/or alcohol test and to furnish a sample of my urine,
breath, and/or blood for analysis, as shall be determined by G & D Installation, Inc. (the Company) in order
to meet with their policy regarding the selection of applicants for employment.
I further authorize and give full permission to have the Company and/or its authorized agents and physicians to send the
specimen or specimens so collected to a laboratory for a screening test for the presence of any prohibited substances
under the policy, and for the laboratory or other testing facility to release any and all documentation relating to such
test to the Company. I further agree to and hereby authorize the release of the results of said tests to the Company.
I understand that it is the current use of illegal drugs and prior convictions that would prohibit me from being employed at this Company.
I further agree to hold harmless the Company and its agents and physicians from any liability arising in whole or part, out
of the collection of specimens, testing, and use of the information from said testing in connection with the Company's
consideration of my application of employment.
I further agree that a reproduced copy of this pre-employment consent and release form shall have the same force and effect as the original.
I have carefully read the foregoing and fully understand its contents. I acknowledge that my signing of this consent and release
form is a voluntary act on my part and that I have not been coerced into signing this document by anyone.