Employer Drug & Alcohol Testing Request

Employer Drug & Alcohol Testing Request
Employer Information
Company Name
Contact Person

First NameLast Name
Contact Email
example@example.com
Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Authorized Results Recipient

Test results will ONLY be released to the individual(s) listed below.
Recipient Name

First NameLast Name
Title
Secure Email Address
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Donor Information
Donor Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Date of Birth

MonthDayYear
Donor ZIP Code

Street Address

Street Address Line 2

CityState / Province

(The test will be performed near this zip code)
Donor Email (To Receive Test Pass)
example@example.com
Donor ID
Example: Employee ID, Phone number or unique ID of at least 6 digits

Employer Information