SELF EMPLOYEE ORDER FORM SELF EMPLOYEE ORDER FORM SELF EMPLOYEE ORDER FORM COMPANY NAME * Did your employer authorize you to schedule under this account? (Results won't release to anyone other than the employer on file) Yes, I am authorized No, I do NOT have authorization Employee Name * First Name Last Name Date of birth * MM DD YYYY Phone * (###) ### #### Email * Zip code for testing: * Desired location (If any) (Location may not be available based on specific test) What time were you looking to go in? Hour Minute Second AM PM Are you responsible for payment? * Employer is responsible I am responsible (pay invoice now) Message In a few moments you will be receiving your barcode authorization which will include the address to where you will be testing. Provide the barcode to the facility when you arrive. * I Understand Thank you!