Employer Onboarding Form

Company Name

Company Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

DOT NUMBER

Industry Type

DER Contact Name

First NameLast Name

DER Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

DER Email Address

example@example.com

Services Requested

Billing Contact Name

First NameLast Name

Billing Email

example@example.com

Billing Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Preferred Method Payment

By submitting this form, the employer authorizes Legacy Mobility Services to perform requested drug and/or alcohol testing services in accordance with applicable DOT and non-DOT regulations and company policies. The employer agrees to provide accurate donor and scheduling information and acknowledges that mobile service fees, after-hours fees, cancellation fees, and no-show charges may apply. Payment is due according to the agreed billing method and terms. Legacy Mobility Services reserves the right to refuse or discontinue services for non-payment, unsafe collection environments, or non-compliance with testing procedures. The employer authorizes electronic communications, records, and signatures related to testing services and understands that all services are subject to availability, laboratory processing requirements, and applicable federal and state regulations.

Acknowledgment

Signature

Date