Client Set Up Form
Employer Name
*
Employer Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Business Type
Number of Employees
Job Titles
*
Departments
*
Hours of Operation
Employer Billing Contact Name
*
First Name
Last Name
Billing Contact Phone
*
Format: (000) 000-0000.
Billing Email Address
*
example@example.com
Billing Fax Number
Format: (000) 000-0000.
Employer Authorization and Results Contact Name
*
First Name
Last Name
Authorized Contact Phone
*
Format: (000) 000-0000.
Authorized Contact Email Address
*
example@example.com
Authorized Contact Fax Number
Format: (000) 000-0000.
Notes
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
2 digit month, 2 digit day, 4 digit year
Date
Authorized Employer Contact Name
*
First Name
Last Name
Authorized Employer Contact Signature
*
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