DER *

(Designated Employee Representative)

First Name

Last Name

Select the following *

NON-DOT

DOT

BOTH

Date you were selected or Desired Date *

(Depending on your customized random)

MM

DD

YYYY

Desired Time *

Hour

Minute

Second

AM PM

On-site contact

First Name

Last Name

Phone

(###)

###

####

For on-site, once this form is submitted, you will receive an invoice for up-front payment in order to confirm the on-site date. If your account is set up with a valid credit card on file, we will send an invoice for payment after the service. You will receive an email to confirm your date. Be sure that your DOT random testing is completed before the deadline. *

I Understand

INVOICE OPTION: *

Pay now (No card on file)

Invoice me, I have an account with a valid card on file

Payment has been previously made

Charge card on file automatically for this service