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City of Eugene <br />Alcohol and Drug Abuse Policy <br />AND <br />Testing P60cedures <br />In Compliance With <br />Federal Motor Carrier Safety Administration Requirements <br />EMPLOYEE CERTIFICATION FORM <br />1, the undersigned employee of the City of Eugene, hereby certify that I have received, <br />read and understand the City of Eugene's Drug and Alcohol Abuse Policy pertaining to <br />implementation of the Federal Motor Carrier Safety Administration's (FMCSA), rules and <br />regulations regarding alcohol and controlled substances testing on individuals <br />performing safety-sensitive functions. I understand that the original of this certificate will <br />be placed in my official personnel file as a record documenting my receipt of said policy. <br />Employee Name (Print or Type) Date <br />Employee Signature <br />City of Eugene Page 7-17 DOT/FMCSA Ding & Alcohol Policy <br />September 2010 Information Packet <br />