SCHEDULE COMPLIANCE TESTING SCHEDULE NON-DOT COMPLIANCE TESTING SCHEDULE NON-DOT COMPLIANCE TESTING REFERRAL - JOANNE BACOURT (COMPLIANCE DEPARTMENT) JOANNE BACOURT (COMPLIANCE DEPARTMENT) COMPANY NAME: * REQUESTER'S NAME * First Name Last Name Phone * (###) ### #### Email * IS THE EMAIL ABOVE THE SAME TO SEND RESULTS TO? * YES NO Email for results if not same as above: ACCURATE TEST REASON * PRE-EMPLOYMENT RANDOM POST ACCIDENT FOLLOW UP REASONABLE SUSPICON FOLLOW UP RETURN TO DUTY OTHER TEST(S) NEEDED TO SCHEDULE * (select both options if both tests need to be done) 5 PANEL 10 PANEL BREATH ALCOHOL NON-DOT PHYSICAL ALC (8-HOUR LOOKBACK) ETG (80-HOUR ALC LOOKBACK) OTHER OTHER (iF APPLICABLE) ADD ONS INSTANT (5 & 10 PANEL INSTANT AVAILABLE ONLY) BODY HAIR (+$20) DOES THE TEST NEED TO BE OBSERVED * (If this test requires moniToring) NO YES, OBSERVED COLLECTION (+$20) DONOR INFORMATION Zip code for testing * DONOR NAME * First Name Last Name Phone * (###) ### #### DATE OF BIRTH MM DD YYYY Email for location Information MULTIPLE DONORS (Please provide information here if you are scheduling multiple donors) INVOICE TYPE * PAY UP FRONT (NO CREDIT CARD ON FILE) INVOICE ME (MUST HAVE A VALID CARD ON FILE) USING CREDIT I HAVE ON MY ACCOUNT CHARGE CARD AUTOMATICALLY FOR ANY REQUESTED SERVICES Thank you!