Acknowledgement Form

CODE: EEAEAA-E

M.S.A.D. #31

23 Cross Street

Howland, Maine 04448

ACKNOWLEDGMENT

I certify that I have received a copy of the M.S.A.D. #31 Administrative Rule on Driver Alcohol and Drug Use and Testing and other printed material explaining the effects of an alcohol and/or controlled substances problem.

Dated:

(Driver's Signature)