Participant Name*
Address*
Contact Number*
Date of Birth*
Gender*
- Male
- Female
Participant declaration
I confirm that I have taken the following medications, drugs or other non prescribed preparations in the last 14 days*
- I consent to the collection of breath, urine, oral, and/or fluid specimen for testing for traces of alcohol and/or other drugs.
- I certify that the information provided on this form is correct and the sample provided is my own.
- I confirm that I have directly provided all collected samples to an authorised collector.
- I confirm testing performed was done so in my presence.
- I consent to the release of all test results together with all relevant details and notations on this form to the nominated representative of the requesting authority.
Participant Signature*
Parent/Guardian Signature (required if participant is under 18 years old)
Parent/Guardian Full Name (required if participant is under 18 years old)
First Last
Date*
DD slash MM slash YYYY

Participant declaration