Belte r r a Cor p or at ion S afety M an ual D oc I D C H S M BE L 2 0 1 7 Pa g e 4 86 of 53 8 D R U G A N D A L C O H OL R ET U R N T O W OR K A GR EEM E N T Doc u m e n t Identif icat ion F R M 028 P age Nu m b e r 1 of 1 Doc u m e n t 1 st C r e at e d J an 1 2013 Im p le m e n tat ion Dat e o n Re vised Doc u m e n t Oc t 15 2016 I ac k no wl e dg e tha t I h av e te s ted po s i t i v e f or a Dr u g o r A l c oh ol or tha t I ha v e ref us ed to s u bm i t to a t es t i n v i o l at i on of B e l terr a s Dr ug an d A l c oh ol P o l i c y A s a c on d i ti on of m y e m pl o y m en t wi th B e l terr a Cor po r ati on the Com pa n y I am ex ec uti n g t h i s r etu r n to wor k ag r ee m en t a nd I prom i s e t o a b i de b y i ts term s I a gree to es tab l i s h a t r ea t m en t p l an i n c o ns ul t ati on wi th B e l terr a s E m pl o y e e a nd Fam i l y A s s i s ta nc e P r og r a m E F A P s erv i c es pro v i de r a nd t he a pp r op r i ate s u bs tan c e ab us e p r of es s i on a l s S A P s an d t o f ol l o w an y tre atm en t rec o m m en de d b y t he m I a c k no w l ed g e a nd ag r ee t ha t I m a y s ub j ec t t o t h e s p ec i f i c c i r c u m s tan c es b e t er m i na ted i m m ed i ate l y w i t ho ut f urther no ti c e or c om pe ns ati o n i f I e ng ag e i n c on d uc t p r oh i b i ted b y t he P o l i c y I f ai l t o m ee t wi th m y S A P s as r ec om m en de d I d o no t c om pl y wi t h t h e t r e atm en t p r og r am de term i ne d b y m y S A P s I ref us e t o t es t f or Dr ug s a n do r A l c oh ol as s et ou t i n t h e P o l i c y I ref us e t o t es t f or Dr ug s a n do r A l c oh ol as de t erm i ne d ne c es s ar y b y m y S A P s I h ereb y gi v e pe r m i s s i on to the C om pa n y to c on tac t an y of m y do c t or or ot he r S A P s to c on f i r m T ha t m y ad d i c ti o n i s i n rem i s s i on an d t h at h e o r s h e d o es no t ha v e a n y r ea s on to be l i e v e t ha t I w o ul d ot h er w i s e c o m pro m i s e s af et y T ha t I am c on ti nu i ng wi th a nd c oo pe r at i ng w i t h a l l r ec o m m en de d o n go i ng treatm en t a n d t h at t he p l a n i s ap pro pria t e t o as s i s t m e t o s us tai n rem i s s i on T ha t m y S A P c on ti n ue s to s ee m e o n a r eg ul ar ba s i s an d c o nti nu es t o m on i tor m y r em i s s i on T ha t m y S A P wi l l i m m ed i at el y i nf o r m Hu m an Res ou r c es i f I e x pe r i en c e a rel ap s e of th e a d di c t i on or i f I c ea s e t o c on s ul t hi m or her on a reg ul ar b as i s a nd If I h av e no t y e t ret urned to wor k m y S A P m a y a l s o a s k f or a progn os i s as to t he l en gt h o f ti m e t ha t I wi l l be o ff wor k i f an y T hi s ag r ee m en t s ha l l c on s ti tut e m y f ul l c on s e nt t o m y S A P s t o p r o v i de t he ab o v e i nf orm ati on to t he C om pa ny Da ted this da y of 201 loca ted a t Empl o y e e S i g na tur e S upe rvisor Huma n R e sourc e s R e pre se ntative F ull Na me F ull Na me S ig n S ig n Da te Da te