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9 <br />NON-FEDERAL <br />Drug & Alcohol Testing Consent Form <br />Current Employees – MRO <br /> <br />I acknowledge that I have received, read and understand the City of Mounds View’s Policy <br />and Procedure for Drug and Alcohol Testing (“Policy”). I understand that this Policy does <br />not alter the at-will nature of my employment. <br /> <br />I hereby agree to submit to drug and alcohol testing under the City’s Policy. <br /> <br />I also understand that test results and other information acquired in the drug and alcohol <br />testing process may be disclosed to and discussed with a Medical Review Officer <br />(“MRO”). I hereby consent to such test results and other information being disclosed to <br />and discussed with an MRO. <br /> <br />Employee Information: <br /> <br /> <br /> <br />Signature Date <br /> <br /> <br /> <br />Print Name <br /> <br /> <br /> <br /> <br />Witnessed by: <br /> <br /> <br /> <br />Signature Date <br /> <br /> <br /> <br />Print Name <br />