aPPLICATION QUESTIONAIRE

APPLICANT QUESTIONNAIRE

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EDUCATION & TRAINING

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EMERGENCY CONTACT

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REFERRAL SOURCE

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DISCLOSURE STATEMENT

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DRUG SCREEN CONSENT

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I hereby authorize and give full permission to have USP Inc. and /or their medical company physician send a specimen of my urine and /or blood to a laboratory for screening test using Substance Abuse & Mental Health Services Administration standards for the presence of illegal drugs, alcohol, or prescription medication taken without prescription.

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I will hold all parties concerned harmless, meaning I will not sue nor hold responsible for alleged harm to me or interfering with my obtaining job or continuing employment due to not submitting to the tests or as a result of the report of the tests. This includes, but not limited to, possible clerical or laboratory error. This policy and authorization has been explained to me in a language I understand and told if I have any questions they will be answered. I understand this is a legal and binding document, which is binding because USP Inc. is sending me for examinations.

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I UNDERSTAND THAT USP INC. WILL REQUIRE A DRUG SCREEN TEST WHENEVER A JOB ACCIDENT OR INJURY IS REPORTED ACCORDING TO THIS STAFFING COMPANY POLICY AND THIS AUTHORIZATION AND CONSENT FORM.

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MY REFUSAL TO SUBMIT TO A DRUG TEST WILL BE GROUNDS FOR TERMINATION.

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EMPLOYMENT AGREEMENT

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I understand that I am an employee of USP Inc. and I understand I am under contract obligation to adhere to USP Inc. rules and regulations when I accept a position with USP Inc. I also understand that I must adhere to the rules that are governed by the client you send me to work for. In any event that the client is interested in hiring me or I want to work for them directly, I must wait a total of 90 days before changing over after my start date of hire. Be advised that the client must also adhere to any prior agreements. Any violations of these rules may be sent to Maryland Courts for dispute of any charges that may arise.

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By signing this document, I understand that the rules explained above and agree to follow the rules and regulations when I accept a position with USP Inc.

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By clicking SUBMIT below, I hereby declare that all statements contained in this application are true and understand that any false or inaccurate information will be the basis for termination. I hereby authorize USP Inc. to investigate my background inclusive of criminal records and verify this information. I understand and agree that I may be expected to work on a variety of job assignments in the Greater Metropolitan area and understand that if employed, my employment will not be for any fixed period of time and may be terminated by the company at any given time. I authorize USP Inc. to release the information contained and submit a drug screen to other firms and persons upon request.

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