I hereby certify that I personally completed this form, and that the information is true, correct, and complete, to the best of my knowledge.  I authorize St. Henry Tile Co., Inc. to obtain information relating to my past or present work history in accordance with state and federal laws.  Furthermore, I give my express consent for St. Henry Tile Co., Inc., any previous employer, their agent, or Medical Review Officer or their agent to release information concerning any of my past controlled substance tests.  I release all persons from any liability or damages.  I authorize release of any information, including all information related to my alcohol and controlled substances testing and training records, by any former employers and hold them harmless of any liability from release of said information.