Drug & Alcohol Testing Program Account Set-up Form
Company Name*
Physical Address (no PO Boxes)*
Street Address
Street Address Line 2
City State / Province
Postal / Zip Code Country
Add a Mailing Address?
Yes Same as Physical Address
Mailing Address
Street Address
Street Address Line 2
City State / Province
Postal / Zip Code Country
Company Phone Number
Area Code Phone Number
Primary Contact Name*
First Name Last Name
Primary Contact Title*
Primary Contact Phone*
Area Code Phone Number
Primary Contact Permissions*
Receive Results via emal Receive Results Notification only Billing Contact View Results online Can order Tests Is DER-Designated Employer Representative
Primary Contact E-mail*
Add 2nd company contact?
Secondary Contact Name
First Name Last Name
Secondary Contact Permissions*
Receive Results via emal Receive Results Notification only Billing Contact View Results online Can order Tests Is DER-Designated Employer Representative
Secondary Contact Title
Secondary Contact Phone
Area Code Phone Number
Secondary Contact E-mail
Add Billing Contact?*
Billing Contact Name
First Name Last Name
Billing Contact Permissions*
Receive Results via email Receive Results Notification only Billing Contact ONLY - No Results View Results online ONLY Can order Tests ONLY - No Results Is DER-Designated Employer Representative
Billing Contact Title
Billing Contact Phone
Area Code Phone Number
Billing Contact E-mail
Do you have employees that are DOT Regulated.*
No Yes Not Currently but we will in the future
Will You be conducting random testing?*
YES NO
What specimen types will you be testing?*
Urine Hair Breath Alcohol Oral Fluid
Choose Your Drug Test Panels if you know which ones you will be using.
5 Panel nonDOT 5 Panel nonDOT + Exp. Opiates 10 Panel nonDOT 10 Panel nonDOT + Exp. Opiates nonDOT BAT 10 Panel POCT/Rapid Test DOT BAT DOT 5 Panel Other - Specify Below 5 Panel POCT/Rapid Test
Other Test Panel - or Drugs to be included in testing
Will you Require any of the following? Check all that may apply.
Instant Testing Onsite Testing After Hours Blood Alcohol Random Testing Management
Compliance: Are you interested in any of the following?
Drug Free Workplace Policy Manual or Program Supervisor Training DER (Designated Employer Representative) Training Random Program Management DOT Random Consortium
DOT # (if Applicable)
If DOT Regulated, Enter your DOT number
Notes or Additional Contacts
Enter the message as it's shown*
Should be Empty: