ORDER A DRUG TEST
Company Name
*
Company Phone
*
-
Area Code
Phone Number
Company Contact
*
First Name
Last Name
Company Email
*
example@example.com
Primary ID (SSN)
*
Driver Name
*
First Name
Last Name
Primary Phone Number
*
-
Area Code
Phone Number
Secondary Phone Number
-
Area Code
Phone Number
Date of Birth (mm-dd-year)
*
Driver zip code (need for electronic locations)
*
Gender
Male
Female
Test Reason
*
Pre-employment
Random
Reasonable Suspicion/cause
Follow Up Test
Post Accident
Other
Test Date (mm-dd-year)
*
Test expiration date (mm-dd-year)
*
Any Special Instructions
***NOTICE*** some locations are NOT electronic, which means the driver will have to have a custody form with them to take the test. If you are sending the driver to a non-electronic facility, please include the custody form control number below.
control number
Name of person authorized to order this test
Sign here
Submit
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