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Enrollment Form

Whether you are a seasoned employer with a well-established drug testing program or a company just starting your first drug and alcohol program, SECURE RESULTS can provide the MRO services to meet all of your company's needs.

Enrollment Form

•	Workplace Testing
•	Personal Testing
•	Court Order Tests
•	On Site Testing

“Call us toll free at 1-877-340-6101 to help enroll you in the program that fits your needs”

Please complete this form and return to us by e-mail (DrMartin@SecureResults.net)
or by fax: 215-340-6184.

Company Name
Alias
Address

(If more than one address, please attach a separate sheet with complete demographic information (or click here) and contact person if different from primary location.)

Phone
Fax
E-mail

Authorized Contacts	1.
	2.

Type of Industry?

Government regulated

Private

Number of employees?

If government regulated:

	FMCSA		FAA		USCG		FRA
	FTA		RSPA		DOD		NRC

If private industry, do you have a drug testing policy?
	Yes (please attach)		No

If private industry, what are the categories of substance testing?
	Pre-placement
	Post-accident
	Reasonable suspicion
	Random; What percentage and frequency?
	Return to work

If you do not have a substance abuse policy, do you need assistance with the development of one?

Yes

Results Reporting

How would you like to receive test results?

Secure Fax

E-mail

Mail

Secure Results Web Site

Please indicate if the destination of test results are different than already listed on this form or indicate “same”:
Secure fax
E-mail
Mail
Billing Information: (indicate “same” if already listed)
Address
Contact Person
Telephone
Fax
E-mail