True North Mobile Drug Testing Client Onboarding
Company Information
Business/Organization Name
DBA, if applicable
Business/Organization Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Primary DER/Authorized Contact Name
Title/Role
Primary Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Primary Email
example@example.com
Is Primary Contact authorized to receive collection status & lab/MRO results?
Yes
No
Preferred Method of Contact?
Phone
Email
Both is Ok
Secondary DER/Authorized Contact Name
Secondary Title
Secondary Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Secondary Email
example@example.com
Business/Organization Website
Type of Organization
Staffing Agency
Trucking/Transportation
Construction
Healthcare
Sober Living/Recovery Program
Government/Manicipality
Individual
Other
Approx. # of Employees or Residents
After-Hour or Weekend testing needed?
Yes
No
After-Hours Phone Number, if applicable
Please enter a valid phone number.
Format: (000) 000-0000.
Type of Services Needed?
Pre-Employment DOT Urine Drug Testing
Pre-Employment Non-DOT Urine Drug Testing
DOT Alcohol Testing
Non-DOT Alcohol Testing
Random Urine Drug Testing
Reasonable Suspicion Urine Drug Testing
Return to Duty Urine Drug Testing
After-Hours Urine Drug/Alcohol Testing
If DOT, regulated?
Yes
No
N/A
Estimated Monthly Testing Volume
Desired Start Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Billing Information
Preferred Billing Method?
Invoice/Credit Card/Debit Card
Check
ACH
Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Service Agreement Acknowledgement
By signing below, the Client agrees to the pricing, service conditions, and policies outlined in this document. True North Mobile Drug Testing agrees to provide professional services in accordance with industry standards and applicable regulations.
Authorized Contact Name
Title/Role
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Continue
Continue
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