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Screening & Inspection Authorization & Consent

The Company has a policy against drug and alcohol abuse and reserves the right to screen its employees and applicants for employment as an enforcement measure in providing a safe, healthy, and productive working environment.

By my signature below, I am freely and voluntarily agreeing and consenting to submit a personal specimen of urine and/or blood for chemical analysis and testing to determine or rule out the presence of illegal, abused, or prohibited drugs/alcohol or substances in my body fluids.


I hereby authorize the Company's duly appointed collection facility, or Company and testing laboratory, and their

personnel, to obtain, process, and test the specimen and to release and discuss the results of the analysis and test to the authorized agent at Maxum Petroleum for employment purposes. Said information will be handled as confidentially as is

reasonably possible, shared only on a "need to know" basis.


I understand a documented chain of custody exists to ensure the identity and integrity of my specimen

throughout the collection and testing process.


As an applicant, I understand that if I have a positive test or refuse to submit to this drug/alcohol screening

analysis and test, this will constitute voluntary withdrawal of my application for employment and no further consideration shall be given. As an employee, I understand that if I have a positive test or refuse to submit to this drug/alcohol screening

analysis and test, this will constitute a violation of Company policy and I will be subject to disciplinary action up to and including termination of employment.


I hereby release, forever discharge, and hold harmless the Company, any physician, technician, medical facility,

and laboratory facility and all of their respective officers, directors, employees, representatives, and agents from any and all claims of whatever nature arising out of or in connection with any act or omission relating to any (1) examination, (2) test, (3) collection, (4) procedure, (5) chain of custody, (6) disclosure, (7) analysis, (8) diagnosis, (9) inaccuracy, (10) report,

or (11) action performed.


In consideration of my personal desire for as safe a work environment as possible, I hereby voluntarily give my

consent for the Company to search my person, personal effects, vehicle, and other property located on Company premises

or worksites, including Company vehicles.


I certify that I have read this form, or it has been read to me and I understand its contents. I also certify that I have

received a copy of the Maxum Petroleum Drug and Alcohol Abuse Prevention and Testing Policy and Exhibits.


I understand that, like all other Company forms, this form does not alter the employment at‐will relationship. I or

the Company may terminate my employment at any time for any reason or no reason at all with or without notice.

_________________________________________ ______________________________________ Applicant Name(Print)- Applicant Signature Date Witness Name (Print)- Witness Signature Date

2011 Maxum Petroleum, Inc.

500 River East Drive | Belle, WV 25015 | (304) 926-3002 | www.maxumpetroleum.com

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