Drug Test Employer Account Set Up Form

Drug & Alcohol Testing Program Account Set-up Form

Company Name*

Physical Address (no PO Boxes)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Add a Mailing Address?

YesSame as Physical Address

Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Company Phone Number

Primary Contact Name*

First NameLast Name

Primary Contact Title*

Primary Contact Phone*

Primary Contact Permissions*

Primary Contact E-mail*

example@example.com

Add 2nd company contact?

Secondary Contact Name

First NameLast Name

Secondary Contact Permissions*

Secondary Contact Title

Secondary Contact Phone

Secondary Contact E-mail

example@example.com

Add Billing Contact?*

Billing Contact Name

First NameLast Name

Billing Contact Permissions*

Receive Results via emailReceive Results Notification onlyBilling Contact ONLY - No ResultsView Results online ONLYCan order Tests ONLY - No ResultsIs DER-Designated Employer Representative

Billing Contact Title

Billing Contact Phone

Billing Contact E-mail

example@example.com

Do you have employees that are DOT Regulated.*

NoYesNot Currently but we will in the future

Will You be conducting random testing?*

YESNO

What specimen types will you be testing?*

UrineHairBreath AlcoholOral Fluid

Choose Your Drug Test Panels if you know which ones you will be using.

Other Test Panel - or Drugs to be included in testing

Will you Require any of the following? Check all that may apply.

Compliance: Are you interested in any of the following?

Drug Free Workplace Policy Manual or ProgramSupervisor TrainingDER (Designated Employer Representative) TrainingRandom Program ManagementDOT Random Consortium

DOT # (if Applicable)

If DOT Regulated, Enter your DOT number

Notes or Additional Contacts

Enter the message as it's shown*