Employee Screening Management - National Student Drug Testing

Downloadable Forms

Account Set-up Form

Sales Rep:
Date: ................ Acct. Type: DOT Non HRS(FL) Location Code
Company Name: Contact:
Address: City:
State: ........ Zip: Phone: Fax:
Comments:

1. Reporting to: MRO .... Quant ......Qual ....All results .... Pos/only
Company (same as above ) /MRO Name
Address: City:
State: ........ Zip: Phone: Fax:
2. Reporting to Company: Non DOT .... Quant or Qual ....All
Company (same as above )
Address: City:
State: ........ Zip: Phone: Fax:

Results by: ...Fax ... Software ... Mail ... E-Mail
Comments:
Supplies/Ship to: (same as above ) .................Pre-Print collection site: ......N Y
Company
Address: City:
State: ........ Zip: Phone: Fax:
Comments:
First order due: ....Standard shipping ...Overnight ....2nd Day
Kits and forms: DOT ..... Split kits .....Small Lab Pacs
COC Non DOT 5 Part .....Single Kits ..... Large Lab Pacs
COC Non DOT 7 Part .....Blood/Alco .....Supply form
Comments:

Billing To: (same as above ) or Company:
Address: City:
State: ........ Zip: .....Phone: ..... Fax:
Comments:
Test Panel Cost: DOT .....NON 5 ..... NON 7 .....NON 10
Custom Panel Cost: Panel Name (ex. 6panel)
Check: Coc	THC	Amp	Opiate	Phen	Benzo	Barb	Meth
Propoxyphene ...Methadone ..... THC mg level 20 mg 30 mg 100mg
GCMS Only .... D/L .... 6MAM .... Urine Alcohol .... BI/AI
Date complete:			Date supplies are to ship:

Contact Employee Screening Management at info@pre-screen.com or 1.888.371.4615 for additional information.