Employer Drug & Alcohol Testing Request

Employer Drug & Alcohol Testing Request
Employer Information
Company Name *
Contact Person *

First NameLast Name
Contact Email *
example@example.com
Contact Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Authorized Results Recipient

Test results will ONLY be released to the individual(s) listed below.
Recipient Name*

First NameLast Name
Title*
Secure Email Address*
example@example.com
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Donor Information
Donor Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Date of Birth*

MonthDayYear
Donor ZIP Code*

Street Address

Street Address Line 2

CityState / Province

(The test will be performed near this zip code)
Donor Email (To Receive Test Pass)*
example@example.com
Donor ID*
Example: Employee ID, Phone number or unique ID of at least 6 digits

Employer Information