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1 <br />482 <br />CITY OF PARIS <br />INFORMED CONSENT AND <br />RELEASE OF LIABILITY MEDICAL. AUTHORIZATION FORM, <br />CONSENT FORM FOR SUBSTANCE TESTING <br />I hereby give my consent to a medical examination including, but not limited to, the <br />collection of a breath, urine, or blood sample to be submitted for an alcohol, drug, and controlled <br />substance abuse screening tests, in accordance with the City of Paris's Controlled Substance and <br />Alcohol Abuse Policy. Further, I hereby consent to the release of the test results to those City <br />officials who make employment decisions, for the City., I under -stand that -any positive result from <br />such test, which indicates my inability to safely and successfully perform the essential functions of <br />the position for which I am being employed or am currently employed, may preclude my receiving <br />or continuing employment. I release, relinquish, and remise the City of Paris, its employees, <br />agents, and representatives, from any and all causes of action or liability which I may have or <br />which arise out of, or as a result of, the examinations herein authorized. Furthermore, I understand <br />that my failure to execute this informed consent will, if I am applying for employment, result in my <br />not being further considered for employment, and may, if I am currently employed, result in my <br />discharge. <br />Signature Date <br />Name (please print) Department/Division <br />85' Revised 01 -25 -05 <br />