Applicant’s Authorization and Release to Check References
Applicant’s name: ___________________________________________________________
Applicant’s address: __________________________________________________________
___________________________________________________________________________
Social Security No: _________________ Telephone No.: ____________________
Applicant's Authorization and Release
I hereby authorize Employer, its directors, officers, employees and agents to contact, obtain, and
verify the accuracy of information concerning references which I have specified in my Employment
Application. I also release the Employer and those companies and individuals acting under this
release from any and all liability and damage arising out of or relating to the information furnished the
Employer by such references. Such release covers all tort and contracts claims, including, but not
limited defamation and negligence.
I understand that this Authorization and Release will permit my references to give the Employer
information about me relating to the following: [Applicant to initial line next to information which
References may give to Employer]
___ Dates of Employment
___ Positions held
___ Attendance
___ Disciplinary actions/warning letters
___ Overall job performance
___ Salary
___ Reasons for employment termination
___ Rehireability.
Dated: ____________________.
_________________________________
Applicant’s signature
Witness:
___________________________
Signature
___________________________
Printed name
Applicant’s Name: ____________________Social Security #___________________
DRUG AND ALCOHOL TESTING CONSENT AND RELEASE
Royal Thai Spa is committed to providing a safe work environment for all employees. When employees are impaired due
to the use of drugs or alcohol, they become a safety hazard to themselves and others in the workplace. Our company
provides for a drug screen in support of our drug free workplace policy. Attached to this Consent and Release is the
Company’s Drug Free Workplace Policy. Please read this Policy prior to signing this form.
Consent/Release
I, _________________________________, have been fully informed of the reason for a drug screen. I understand the
reason for the testing and the procedure involved. I freely give my consent. I also understand that the results of a drug
screen are considered part of my employment application and any employment decision including being rejected as a
candidate for employment or promotion. If hired, I consent to alcohol / drug screening as part of my continued
employment and as provided in the Company’s Drug-free workplace policy as amended from time-to-time. If I am not
hired as a result of a positive test, I will be given the opportunity to confidentially explain the reason.
Further, I freely and willingly consent to the disclosure of the screen results to the management of the Company for use
in internal communications and to such other persons as the Company believes needs to be informed of the test screen
results; subject to the confidentiality provided by the Policy and applicable law.
I voluntarily fully release and waive all claims that I may now have or in the future may have against the Employer, its
representatives, agents, and employees and any laboratory or any other facility and their representatives and agents,
which perform analyses or have access to the results of such test(s), from any claim or liability arising from such tests,
including, but not limited to the testing procedure, the analysis, the accuracy of the analysis or the disclosure of its
results, defamation, interference with contract, or prospective economic advantage and negligence .
I understand the alcohol / drug screens may detect the presence of prescription drugs and over-the-counter medications.
Therefore, it is important for me to disclose any prescription drugs and over-the-counter medications I am using, or
which I have used recently. I authorize the Company or its agents to contact the physician who prescribed medications
reported by me. Further, I authorize the physician to provide information to the Company or its agents relevant to the
reason for such prescription and information about its potential effect on my performance.
I have taken the following drugs or ingested the following alcohol/drug substances in the last seven days:
Substance/Medication
Prescribed By
Amount (Dosage)
Date Last Taken
Substance/Medication
Prescribed By
Amount (Dosage)
Date Last Taken
Over-the-Counter
Medications
Reason for Taking
O-T-C- Medications
Amount (Dosage)
Date Last Taken
Duration of Consent / Certification of Accuracy
Should I become an employee, I acknowledge that this consent shall remain valid for my entire period of employment. I
certify that I have accurately provided all requested information on this form. I understand that any inaccuracies or
omissions, willful or unintentional is grounds for disciplinary action up to and including termination of my employment
or my being denied employment at Royal Thai Spa LLC.
PLEASE READ THE ATTACHED COMPANY POLICY ON SUBSTANCE ABUSE BEFORE SIGNING THIS
CONSENT AND RELEASE.
APPLICANT’S NAME (printed):
SIGNATURE:
_________________________________
__________________________________
DATE SIGNED:
__________________________________
SOCIAL SECURITY NUMBER:
__________-______-___________
HOME TELEPHONE NUMBER:
__________________________________
HOME ADDRESS:
__________________________________
__________________________________
WITNESS SIGNATURE:
__________________________________
WITNESS PRINTED NAME:
__________________________________