ORDER A DRUG AND ALCOHOL TEST
Company Name
*
Company Contact
*
First Name
Last Name
Company Email
*
example@example.com
Company Phone Number
*
-
Area Code
Phone Number
Driver Cell Phone (Driver must be contacted in case any issues with their test)
*
-
Area Code
Phone Number
Primary ID (SSN)
Driver Name
*
First Name
Last Name
Driver License #
*
Exp Date
*
License State
*
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
Type of test requested
*
Drug Test
Drug & Alcohol Test
Alcohol testing is not required for pre-employment testing
Test Reason
*
Pre-employment
Random
Reasonable Suspicion/cause
Follow Up Test
Post Accident ( If the driver was issued a moving citation, then he/she must perform a drug&alcohol test. If a citation was NOT issued, the a drug & alcohol test is NOT required)
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. I also understand that if the test is for a "pre-employment" we are assuming you are hiring this driver, and they will be added to your account, unless you notify us that you are not hiring the driver. Test results will be emailed to you attached to the receipt.
*
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