“Call us toll free at 1-877-340-6101 to help enroll you in the program that fits your needs”Company Name Alias Address Additional Addresses Phone Fax Email Authorized ContactsType of Industry Government RegulatedPrivateIf government regulated FMCSAFTAFAARSPAUSDGDODFRANRCNumber of employees If private industry, what are the categories of substance testing? Pre-placementPost-accidentReasonable suspicionRandomReturn to workIf random, what percentage and frequency? If you do not have a substance abuse policy, do you need assistance with the development of one? YesNoResults ReportingHow would you like to receive test results? Secure FaxEmailMailSecure Results WebsitePlease indicate if the destination of test results are different than already listed on this form or indicate “same”:Secure Fax Email Mail Billing Information: (indicate “same” if already listed)Address Contact Person Telephone Fax Email
