Name

If you are offered or are now employed with Speed-E'Z, in interest of safety for all concerned, you may be required to take a urine or hair test for drug / alcohol use. The company reserves the right to perform such testing randomly and at any time, or as many times as the company deems necessary to control drug / alcohol usage among employees. All testing will be fully paid by Speed-E'Z Exchange INC

I, ....................................................................................
have been fully informed of the reason for this test for drug / alcohol usage. I understand what I am being tested for, the procedure involved, and do hereby freely give my consent. In addition, I understand that the results of this test will be forwarded to my employer and become part of my record. If this test is positive, and for this reason I am not hired, terminated, or put on probation; I understand that I will be given the opportunity to explain the results of this test. I hereby authorize these test results to be released to Speed-E'Z Exchange INC.

I hereby authorize these test results to be released to Speed-E'z Physician Exchange.

Signature:

Date:

Please check your forms for accuracy and fax all completed forms to: Fax: 210-576-5496 or mail to:

Speed-E'z Exchange, Inc.
The Park on Medical
4115 Medical Drive, Suite 205
San Antonio, TX 78229