RELEASE AND CONSENT FOR DRUG SCREENING

Kelly Representatives providing service in M aine: Remove and discard this document from the Hiring Kit.
Instead, use the Notification of Substance Abuse Screening for the State of Maine (e426).

Kelly Representatives providing service in Colorado (Boulder only), Connecticut, Haw aii, I ow a,
M aryland, M assachusetts, M innesota, M ontana, N ew Jersey, Oklahom a, Rhode I sland, Utah or
Verm ont: Also provide the Drug-Free Workplace and Substance Abuse Policy (e2400), and ensure the applicant
checks the box below to acknowledge receipt of e2400.

For employment-related purposes, I understand that Kelly Services, Inc. and/or its subsidiaries (Kelly or Kelly
Services) may ask me to submit to screening for drugs, alcohol, inhalants, and/or any other controlled
substances (altogether referred to as drug(s) for the purposes of this Release and Consent form), unless
prohibited by law. Where permitted by law, this may include screening prior to starting a specific customer
assignment, after an accident occurs on the job, on a periodic and/or random basis, or based on reasonable
cause to believe I am under the influence of drugs during work hours while on an assignment. A copy of Kellys
Drug-Free Workplace and Substance Abuse Policy is available through your Kelly Representative, via
myKelly.com, and/or was provided to you.
I hereby consent to submit to drug screening. I further authorize Kelly, its customers, or any hospital, clinic,
laboratory, or medical review officer/organization to conduct and analyze the drug screening and to share the
results among themselves. I agree to complete and sign any paperwork required by the laboratory to perform
the screening and to provide the results as indicated in this Release and Consent form.
I agree that if I refuse to take or delay a required drug screening, alter a specimen, or refuse to complete
necessary paperwork for a drug screening, Kelly may deny me employment, remove me from an assignment,
and/or terminate my employment.
If the screening results are considered unfavorable by Kelly or the customer, I agree that Kelly may deny me
employment, remove me from an assignment, and/or suspend or terminate my employment. The results of the
screening shall be conclusive.
I release Kelly, its customers, and any organization conducting a drug screening(s) from any liability for the
above actions.
I agree to notify Kelly within five days of any criminal conviction for a drug-related offense occurring during my
employment.
I have read this R elease and Consent for Drug Screening, I understand it, and I agree to its terms.

Damonta Maurise Henry

9967

Full Legal Name (Printed)

Last 4 digits of Social Security No.

Signature

Date

Electronic Signature

Date

Candidates applying for positions in Colorado (Boulder only), Connecticut, Hawaii, Iowa, Maryland, Massachusetts,
Minnesota, Montana, New Jersey, Oklahoma, Rhode Island, Utah or Vermont: By checking this box, I acknowledge that I
received a copy of Kellys Drug-Free Workplace and Substance Abuse Policy (e2400).

2015 Kelly Services, Inc.

1375/e1375

R9/15