New Account Setup Form

New Client Setup Form

Please fill out the following form as completely as possible and a
Client Representative will contact you shortly.
*denotes a required field

Company Name*
Contact Name*
Street Address*
City*
State/Province*		Zip/Postal Code*
Country*
Telephone Number*
Fax Number
Email Address

D.O.T. or Non-D.O.T.
Small Trucking Consortium or Non-STC
Use Your State's Workers Comp. Guidelines?
Non-Profit Organization?
Number of Employees
If DOT, Number of DOT Employees
If DOT, Number of Non-DOT Employees

Do you have a Drug Free Workplace Policy in place already?
Will all employees be tested?
Are you currently testing?
What are you currently testing for?
Would you like Medical Review Officer verification?
What type of testing will be administered?
Pre-Employment/Post Offer		Reasonable Cause
Random Selection		Return to Duty
Post-Accident		Need more information on types of testing

If currently testing, where are collections being performed?
Please list additional collection sites you might use here
Answer the following questions only if you are currently testing:
What laboratory are you using?
Who is your Medical Review Officer?
Who is the current Third Party Administrator?
What Testing Panel do you use?

Educational Programs:

Has supervisor training already been received?
If you selected Yes to the question above, please fax certificates to a'TEST
If you have not received supervisor training please choose one of the following:
Has employee training on the Drug Free Workplace Program been completed?
Do you need a parenting program?
Do you require other training?
Any Other Training Required?