Safety Training

Company Name *

Reason For Testing *

Pre-employment

Random

Post Accident

Pre-Access

Reasonable Suspicion

Return to Duty

Follow-up (direct observation)

Other (specify in instructions)

INSTANT Drug Test (In Addition to Lab Based Testing/Additonal Costs Apply) *

Additional Instructions

This Form has been Completed By: *

Company Contact Name *

Donor Arrival (Must be before 3:30 p.m. (M-T), 11:30 a.m. (F) to receive services) *

Company Contact Phone *

Location For Testing *

Dickinson Office

On-Site Services (Appointment Only)

Donor Name *

Please Choose One *

DOT (Must Specify Authority)

NonDOT

TEST AUTHORIZATION FORM