New Client Form

	Required
Audio Questionnaire
Audiometric Test

	Required
PFT Questionnaire
PFT Test

Company Contacts

Who are we allowed to talk if we have issues (positive test results, uncooperative, etc)
1st DER (Main)*

First NameLast Name
E-mail*
example@example.com
Phone Number*
Please enter a valid phone number.
2nd DER (Back-up)

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
In Person Contacts*

Consortium/Third Party Administrator (C/TPA)

Who pulls your company's randoms and tracks your drug tests.
Please Select C/TPA*
If not listed please fill out the below information
C/TPA

NameDBA
Email
example@example.com
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Verification of Accurate Information
By signing below you verify that all information on this form is correct to the best of your knowledge. Should anything change you understand that it is your resposibility to update information with us. If information is not updated via email or submitting another form, you understand that the most current protocol will be followed and you may be required to pay for tests that no longer are required if we aren't informed. Thank you for choosing Badlands Occupational Testing Services to help with all your Occupational Testing needs!
Date

MonthDayYear
Date
Authorized Signature

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Name

First NameLast Name
Should be Empty:

Client Details: