Test Scheduler
Test information
Category of Test
*
Please Select
DOT
NON-DOT
Type of test
*
Please Select
Drug Test
Alcohol Test
Reason for Test
*
Please Select
Pre-Employment
Random
Post Accident
Return to Duty
Follow up
Reasonable Suspicion/Cause
Other
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Company (Employer) Information
Company Name
*
Designated Employer Representative (DER) Name
*
First Name
Last Name
USDOT
*
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Applicant (Employee) Information
Who is taking the test?
Applicant Name
*
First Name
Last Name
Applicant Phone Number
*
Please enter a valid phone number.
Applicant Email
*
example@example.com
Applicant Date of Birth
*
-
Month
-
Day
Year
Date
Applicant Drivers License #
*
Applicant Driver's License State
*
Applicant's Current Location zip code
*
Would you like to schedule more applicants(employees) ?
*
Yes
No
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Applicant (Employee) Information #2
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Date of Birth
*
-
Month
-
Day
Year
Date
Drivers License #
*
Driver's License State
*
Current Location zip code
*
Would you like to schedule more applicants(employees) ?
*
Yes
No
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Payment
My Products
prev
next
( X )
Drug Test
$
75.00
Quantity
1
2
3
4
5
Alcohol test
$
65.00
Quantity
1
2
3
4
5
Credit Card Details
First Name
Last Name
Credit Card Number
Security Code
Card Expiration
Submit
Should be Empty: