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Testing Authorization Form

First Name:
Last Name:
Corp. ID Number:
Social Security Number:
Drivers License:

Covered Worker:


Reason For Test: (Choose one)

Pre Employment
Random
Post Accident
Reasonable Cause
Return to Duty
Reasonable Cause
Follow-up
NON-DOT Annual
Type of Test:
Drug
Breath Alcohol
Drug & Breath Alcohol
Physical
Regulatory Agency
FMCSA     FTA     NON-DOT

FAA     PHMSA     USCG     FRA