Account Please enable JavaScript in your browser to complete this form.Today's Date *Company Name *Address *Address Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePrimary Contact *FirstLast All (Check Email Secondary ContactFirstLastPrimary Office Phone *Primary Cell PhoneSecondary Office PhoneSecondary Cell PhonePrimary Contact Email *Secondary Contact EmailAccount Type (Check All That Apply) *DOTNON-DOTDOT # (If Applicable)Testing Type (Check All That Apply) *Lab Based Testing (Urine, Oral Fluid, Hair)Instant Testing (Urine Only)BothNumber of Employees (Approximate)Current Testing Needs (Check All That Apply) *UrineOral FluidHairBreath AlcoholOther Service Needed (Check All That Apply) *DOT-CDL PhysicalEmployment PhysicalPPD/TB TestingRespirator Fit TestingPulmonary Function TestingBackground ChecksMotor Vehicle Records ChecksHow do you schedule your services?(Check All That Apply) *i3screen Online PortalPaper AuthorizationWe just send them inWhere Do You Test (Check All That Apply) *Carolina Testing Clinics Only (Florence, Conway, Georgetown)Use multiple clinics in the national networkCommentsSubmit
