Employee List

EMPLOYEE LIST

Must be updated annually and at the time of any employee changes.

Tegrete hires service providers to perform services for some clients that require background checks and drug screening of all individuals working inside and outside their facilities.

Note that drug screening is only required by some Tegrete clients.

Please list below all individuals/employees who currently work or may be assigned to work at this location managed by Tegrete Corporation.

Facility Location: __________________________________________________

(enter the facility location serviced by the employees listed below)

Date Drug Screen

Employee Name

I-9 Completed

Date Background

Results of Background Check

Completed

Results of Drug Screening

(Last, First, Middle)

Date of Birth

(“yes” or “no”)

Check Completed

(“x” the result)

(if required)

(“x” the result)

1

____Clear ___Traffic Offense

____Clear

2

____Clear ___Traffic Offense

____Clear

3

____Clear ___Traffic Offense

____Clear

4

____Clear ___Traffic Offense

____Clear

5

____Clear ___Traffic Offense

____Clear

6

____Clear ___Traffic Offense

____Clear

7

____Clear ___Traffic Offense

____Clear

Notes:

The undersigned certifies that the individuals listed above are ALL of the individuals

who currently work at this location serviced for Tegrete.

Company Name

Printed Name of Signer

Title/Position

Signature

Date