Name/DER *

First Name

Last Name

Phone *

(###)

###

####

SERVICES NEEDED *

5 Panel

5 Panel Instant

5 Panel DOT Drug Test

DOT Physical

Non-DOT Physical

10 Panel

10 Panel Instant

12 panel

Urine Alcohol (8-hour alcohol detection)

ETG Urine (80-hour alcohol detection)

Entry Background Check

Standard Background Check

Advanced Background check

OTHER

Are you in need of a DOT POLICY?

(FMCSA ONLY)

Yes

No

DO YOU NEED TO SCHEDULE A TEST NOW? *

YES

NO

I WILL SCHEDULE ON THE WEBSITE

IN THE FUTURE

Would you like a call back? *

YES

NO

EMAIL ME BACK

By creating this account, I agree that payment is due by 1st of every month & that the debit/credit card on file is accurate and up to date. I agree that after 7 days the invoice is not paid, the card on file will deduct the invoice payment. *

I Agree

I Agree to terms & conditions *

I Agree