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Greene County Board of Commissioners COMMISSIONERS Gary Usry, Chairman Angela W. Deering Jeffery L. Smith Dee Lindsey Ernie Filice 1034 Silver Drive, Suite 201 Greensboro, GA 30642 Phone: [PHONE REDACTED] Fax: [PHONE REDACTED] COUNTY MANAGER Byron Lombard DATE: TO: Good Samaritan Hospital FROM: Tracie Beal, Personnel Director Greene County Board of Commissioners RE: Pre-employment Drug Test The following individual has been offered a position with the Greene Coun ty Board of Commissioners pending the successful completion of a pre-employment drug screen: Name: Date of Birth: Social Security Number: Please administer the test and fax the results to [PHONE REDACTED] or they may be e-mailed to me at tbeal@greenecountyga, gov. Charges for the test should be billed to the Greene County Board of Commissioners at the address above. Thank you. ---PAGE BREAK--- Applicant: Print Name: SS#: Applicant: Signature: Date: Witness Printed Witness Guardian Signature (if applicant/employee under Greene County Pre-employment Drug Testing Consent and Release Form Drug Test Blood Alcohol Breath Alcohol Pre-employment I hereby consent to submit to urinalysis and/or other tests as shall be determined by Greene County in the selection process of applicants for employment, for the purpose of determining the drug content thereof. I hereby acknowledge that I have been notified of the requirements of the Greene County Substance Abuse Policy. I agree that Greene County may collect these specimens for these tests and may test them or forward them to a testing laboratory designated by Greene County for analysis. I further agree to and hereby authorize the release of the results of said tests to Greene County. I understand that it is the current use of illegal drugs that prohibits me from being considered for employment with Greene County. I further agree to hold harmless Greene County and its agents from any liability arising, in whole or in part, out of collection of specimens, testing, and use of the information from said testings in connection with Greene County'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.