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—either this online form or the paper authorization provided to the employee.
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:
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date 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 Name
Last Name
Requester's Email
*
example@example.com
Requester's Position
Requester's Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Employee's / Donors Name
*
First Name
Last Name
Reason for Test:
*
Pre-Employment
Post-Accident
Random
Reasonable Suspicion
Follow Up
Return to Duty
Other
Test to be Performed:
*
DOT Drug Test
Drug & Alcohol Consortium Enrollment
DOT Alcohol Test
NON DOT 5 Panel Drug Test
DOT Drug Test + DOT Alcohol Test
NON Dot 8 Panel (Drug & Alcohol)
Other
Special Instructions:
Party Responsible for Payment?
*
Donor/Employee Pays
Bill Company/Employer
Signature
*
Continue
Continue
Should be Empty: