OVERNIGHT DRUG TEST
Any drug/alcohol tests needed between midnight and 8:59am please call first. 469-251-0705
Suggested Testing Date & Time
Please select the date and time for testing. The testing process will take approximately 15 minutes to 3 hours, depending if the donor can produce a quality sample.
Appointment
*
Company's DER
Results will ONLY be sent to the DER (Designated Employer Representative).
Company's Name
*
DER's Name
*
First Name
Last Name
Phone Number
*
Direct number we can contact while testing. This will NOT be shared with the employee completing the test.
Format: (000) 000-0000.
Email
*
This is the email that results will be sent to.
Are These Drug Test Required As A Part Of The Department Of Transportation?
*
Please Select
Yes - I Need DOT Drug Tests
No - I Do Not Need DOT Drug Tests
How would you like for us to send you the results and CCF (chain of custody forms)? *
Please Select
Email
Fax
What is the fax number if you choose for us to fax you the results and CCF?
Testing Address (Or Area/City):
*
Donor #1's Information
The employee completing the drug test.
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Type Of ID:
*
Please Select
Drivers License
CDL
Military ID
Passport
ID Number
*
Reason For Test:
*
Please Select
Pre-Employment
Random
Post-Accident
Reasonable Suspicion
Periodic
Type Of Test
5 Panel Drug Test
10 Panel Drug Test
Breath Alcohol Test
Donor #2's Information
Donor #2's Information
The employee(s) completing the drug test.
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Type Of ID:
Please Select
Drivers License
CDL
Military ID
Passport
ID Number
Reason For Test:
Please Select
Pre-Employment
Random
Post-Accident
Reasonable Suspicion
Periodic
Type Of Test
5 Panel Drug Test
10 Panel Drug Test
Breath Alcohol Test
Donor #3's Information
Donor #3's Information
The employee(s) completing the drug test.
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Type Of ID:
Please Select
Drivers License
CDL
Military ID
Passport
ID Number
Reason For Test:
Please Select
Pre-Employment
Random
Post-Accident
Reasonable Suspicion
Periodic
Type Of Test
5 Panel Drug Test
10 Panel Drug Test
Breath Alcohol Test
Donor #4's Information
Donor #4's Information
The employee(s) completing the drug test.
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
Type Of ID:
Please Select
Drivers License
CDL
Military ID
Passport
ID Number
Reason For Test:
Please Select
Pre-Employment
Random
Post-Accident
Reasonable Suspicion
Periodic
Type Of Test
5 Panel Drug Test
10 Panel Drug Test
Breath Alcohol Test
Donor #5's Information
Donor #5's Information
The employee(s) completing the drug test.
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
Type Of ID:
Please Select
Drivers License
CDL
Military ID
Passport
ID Number
Reason For Test:
Please Select
Pre-Employment
Random
Post-Accident
Reasonable Suspicion
Periodic
Type Of Test
5 Panel Drug Test
10 Panel Drug Test
Breath Alcohol Test
Donor #6's Information
Donor #6's Information
The employee(s) completing the drug test.
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
Type Of ID:
Please Select
Drivers License
CDL
Military ID
Passport
ID Number
Reason For Test:
Please Select
Pre-Employment
Random
Post-Accident
Reasonable Suspicion
Periodic
Type Of Test
5 Panel Drug Test
10 Panel Drug Test
Breath Alcohol Test
Donor #7's Information
Donor #7's Information
The employee(s) completing the drug test.
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
Type Of ID:
Please Select
Drivers License
CDL
Military ID
Passport
ID Number
Reason For Test:
Please Select
Pre-Employment
Random
Post-Accident
Reasonable Suspicion
Periodic
Type Of Test
5 Panel Drug Test
10 Panel Drug Test
Breath Alcohol Test
Donor #8's Information
Donor #8's Information
The employee(s) completing the drug test.
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
Type Of ID:
Please Select
Drivers License
CDL
Military ID
Passport
ID Number
Reason For Test:
Please Select
Pre-Employment
Random
Post-Accident
Reasonable Suspicion
Periodic
Type Of Test
5 Panel Drug Test
10 Panel Drug Test
Breath Alcohol Test
Donor #9's Information
Donor #9's Information
The employee(s) completing the drug test.
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
Type Of ID:
Please Select
Drivers License
CDL
Military ID
Passport
ID Number
Reason For Test:
Please Select
Pre-Employment
Random
Post-Accident
Reasonable Suspicion
Periodic
Type Of Test
5 Panel Drug Test
10 Panel Drug Test
Breath Alcohol Test
Donor #10's Information
Donor #10's Information
The employee(s) completing the drug test.
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
Type Of ID:
Please Select
Drivers License
CDL
Military ID
Passport
ID Number
Reason For Test:
Please Select
Pre-Employment
Random
Post-Accident
Reasonable Suspicion
Periodic
Type Of Test
5 Panel Drug Test
10 Panel Drug Test
Breath Alcohol Test
Signature
Signature
*
DateTime
Submit
Submit
Should be Empty: