Client Set Up Form
Employer Name*
*
Employer Address*
*
Business Type
Number of Employees
Hours of Operation
Employer Billing Contact Name*
*
Billing Contact Phone*
*
Format: (000) 000-0000.
Billing Email Address*
*
example@example.com
Billing Fax Number
Employer Authorization and Results Contact Name*
*
Authorized Contact Phone*
*
Format: (000) 000-0000.
Authorized Contact Email Address*
*
example@example.com
Authorized Contact Fax Number
Service(s) Authorized
Service(s) Authorized
*
Pre-employment Physical
DOT/DMV Physical
DOT Drug Screen
DOT BAT Screen
Rapid Drug Screen
Non DOT Drug Screen
Non DOT BAT Screen
TB Skin Test
TB Questionnaire
Audiogram
Pulmonary Function Test
Respirator Clearance
Fit Testing
OSHA Questionnaire
Other
Date
*
-
Month
-
Day
Year
Date
Authorized Employer Contact Name
*
Authorized Employer Contact Signature
*
124 West Fesler Street
Santa Maria, CA 93458
info@umsmv.com
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