I, the undersigned, ____________________, hereby declare that:

1.	I have been provided with this copy of the Drug-Free Workplace Policy Statement as a special condition of my employment.
2.	I agree tot he conditions that I must observe the dreg-free workplace policy upon my accepting employment with the Department of Education, Government of American Samoa.
3.	I am required to report any and all drug offenses, convictions or violations occurring at my workplace within 24 hours after such violations or convictions.
4.	If I or other members of my organization are convicted of violating the Drug-Free Workplace Act of 1988 as set fort in the Policy Statement and the laws of American Samoa, I may be subjected to participate in a drug abuse rehabilitation program.
5.	I am prohibited by law to use illegal drugs such as cocaine, marijuana, methamphetamine, or any other type of controlled substance on any government properties or while operating government vehicles at any time. Am aware that I will face immediate termination of employment and face conviction as prescribed by the Federal and State or Territorial law.

My signature on this form expresses my acknowledgement of the special conditions that, as an employee of the government of American Samoa, I must comply with and observe the above policy statement during my period of employment. Any infraction of the workplace policy will hold me liable and accountable before the Federal and State or Territorial Law.

 

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Employee Name

Date