Collector Intake Form
Name
First Name
Last Name
Date Of Birth
-
Month
-
Day
Year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Employer
Employer Contact
Reason For Visit
Pre-Employment
Random
Post Accident
Reasonable Suspicion
Return To Duty
Service Requested
DOT Drug Test
Non-DOT Drug Test
DNA Test
Alcohol Test
Background Check
I-9 Verification
Consent: I authorize Elite Compliance & Logistics to collect specimens and perform testing as requested. Results may be released to the requesting employer, laboratory, or authorized agency.
Yes
No
Signature
Date
-
Month
-
Day
Year
Date
Continue
Continue
Should be Empty: