Language
English (US)
Drug Testing Request Form
Who Is Making This Request
*
Enter name of the person making the request for drug testing.
Company
*
Please Select
Michels Corporation
Michels Power Inc
Michels Energy Holdings
Michels Pacific Energy
Michels Utility Services
Type of Test
*
Please Select
Drug Only
Alcohol Only
Drug & Alcohol
Agency
*
Please Select
NON-DOT
PHMSA
FMCSA
Reason for Test
*
Please Select
Pre-Employment
Post-Accident
Random
Reasonable Suspicion
Follow Up
Return to Duty
Other
If other, please fill out reason why below
Other
Name of Employee to be Tested
*
First Name
Last Name
Date of Birth
*
/
Month
/
Day
Year
Date
SSN
PHMSA or NON-DOT Only
Phone Number
Please enter a valid phone number.
Drivers License Number
FMCSA Only
Drivers License State
FMCSA Only
City & State To Be Tested In
*
Date & Time You Would Like To Test
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