Drug Testing Information Form
Who Is Making This Request (Usually Company Representative or DER)
*
Enter name of the person making the request for drug testing.
What email address should results and communication about the test be sent to?
*
Phone Number of Company Representative
*
Company Name
*
Name of Employer
Type of Test
*
Please Select
5 Panel DOT (Department of Transportation)
5 Panel Non DOT (AMP, COC, THC, OPI, PCP)
10 Panel Non DOT (AMP, BAR, COC, THC, MQU, OPI, PCP, BZP, MTD, PPX)
Agency
*
Please Select
NON-DOT
DOT
Reason for Test
*
Please Select
Pre-Employment
Post-Accident
Random
Reasonable Suspicion
Follow Up
Return to Duty
Other
If other, please fill out reason why below
Other
Name of Employee to be Tested
*
First Name
Last Name
Date of Birth
*
/
Month
/
Day
Year
Date
SSN (Social Security Number or CDL # if FMCSA)
*
Phone Number
*
Please enter a valid phone number.
Drivers License Number
*
Drivers License State
City & State To Be Tested In
*
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