Location For Testing *

Dickinson Office

On-Site Services (Appointment Only)

OFFICE HOURS ARE MONDAY-THURSDAY

8:00 A.M. TO 4:00 P.M.

CLOSED FRIDAY'S

Additional Instructions

Company Contact Phone *

Thank you!!!

This Form has been Completed By: *

TEST AUTHORIZATION FORM

Call Us: 701-690-0585

Please Choose One *

DOT (Must Specify Authority)

NonDOT

Donor Name *

Type of Test(s) *

Drug (Lab Based)

Alcohol

Instant (select panel below)

Hair Follicle

Respirator Fit Test-Call 701-690-0585

Company Contact Name *

Company Name *

DOT Testing Authority

FMCSA

PHMSA

FAA

FRA

FTA

USCG

Donor Arrival *

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) *

B&H On-Site Testing LLC 701-690-0585

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