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Us, & XP Drug Screen Result Form Completed by Employer Representative and Donor Employer: Address: City: State: Donor Name: (print) Zip Code: Id Type SS# ID # Reason For Test: Circle the appropriate specimen given: I certify that I am about to provide my oral fluid or urine specimen to the collector. I will not adulterate my specimen in any manner and the information provided on this form is correct. I hereby consent to this test, release and hold harmless the employer and test facility a.

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