DOT Drug Testing Authorization Form

DOT Drug Testing Authorization Form

This form is intended only for companies/employers with an active account in good standing. Please submit only one authorization per test request. Employee/Donor does not need to come in with a printed copy.
HPC Testing Services

1600 E Burnett St, Signal Hill, CA 90755

Tel: (562) 989-5991 Fax: (888) 502-5581

Hours:

Mon-Fri: 08:30 AM - 05:30 PM

Sat: 08:30 AM - 02:30 PM
Date of Test:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate the test is required. Testing will only be completed on date inputted. If employee does not make it on that date employer will have to resubmit a new authorization.
Company/Employer Name:
Requester's Name

First NameLast Name
Requester's Email
example@example.com
Requester's Position
Requester's Phone Number
Format: (000) 000-0000.
Employee's / Donor's Name

First NameLast Name
Reason for Test:

Other
Test to be Performed:

Other
Special Instructions:
Party Responsible for Payment?
Signature
**PLEASE NOTE THAT RETURN TO DUTY AND FOLLOW UP DOT DRUG TESTING MUST BE OBSERVED, PLEASE CONTACT OUR OFFICE TO CONFIRM AVAILABILITY BEFORE SUBMITTING AUTHORIZATION**
Should be Empty: