Free background check form 33
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Please note the following information is for educational purposes only and does not constitute legal advice. Please consult with counsel prior to using
this form as part of your screening process.

As a condition to my employment at

, I agree to submit to a

I understand that the results of this urinalysis, if confirmed positive, may remove me from consideration
for employment at
. A positive test indicates the presence of
marijuana, cocaine, opiates, amphetamines, and/or phencyclidine.
For the sole purpose of this urinalysis, I authorize my Employer’s Authorized Agents to collect samples of
my urine, and to use these samples or to forward these samples to a testing laboratory chosen by
for analysis. I also authorize these results to be reviewed by
a Medical Review Officer (MRO).
Further, I authorize my Employer’s Authorized Agents to release the results of this urinalysis, and any
other related documentation, to Inflection Risk Soluti