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    Employee Consent Form

    I,

    here by authorize my employer, Novitium Pharma LLC to release my personnel information including address, phone number and social security number to the Drug Enforcement Administration (DEA) or to a private security clearance firm to verify my personal details and / or to conduct a criminal background check. I understand that verification of personal details and / or criminal background check are required by Novitium procedures to have access to Controlled Drug Substances (CDS) while I am employed at Novitium Pharma. The foregoing authorization shall continue in force until revoked by me in writing. A photocopy of this authorization shall have the same force and effect as the original.

    (Employee Signature)


    Date


    (Witness)


    Date