Safety Training

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 *

Please Choose One *

DOT (Must Specify Authority)

NonDOT

Donor Name *

Location For Testing *

Dickinson Office

On-Site Services (Appointment Only)

Additional Instructions

Company Contact Phone *

Donor Arrival *

This Form has been Completed By: *

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

TEST AUTHORIZATION FORM