Test Form

Company Info

Company Name*

DBA (if applicable)

Company Address*

Street Address Address Line 2 City State ZIP Code

Same as billing address

Company Phone*

Company Fax

Company Web Address

Company FEIN*

Date of Incorporation*

Contact Info

Contact Name*

First Last

Contact Phone*

Contact Phone (Mobile)

Contact Email*

Additional Info

Please list all Owner, Partners, Officers and Directors

Please list the Name, Title, and Percentage Ownership of each owner

Name	Title	Ownership Percentage

Please indicate all states where you are licensed to do business

Holding down Crtl will allow you to select multiple states.

Please indicate all states where you hold a laboratory license

Holding down Crtl will allow you to select multiple states.

Do you have relationships with labs that are SAMHSA certified?

Yes
No

Please provide list with site names, addresses and phone numbers

Drop files here or

Max. file size: 24 MB.

Do you offer consolidated billing from collection, labs and the MRO?

Yes
No

Please describe invoicing process

Name of Certified Medical Review Officer

First Last

Name of Laboratory Director

First Last

Please describe your compliance program

Please provide a copy of any compliance program materials (if applicable)

Drop files here or

Max. file size: 24 MB.

Please describe the privacy and security safeguards the entity uses to protect individually identifiable information

Do you have electronic chain of custody forms available?

Yes
No

Can you facilitate the setup of drug testing anywhere in the nation with no additional charge?

Yes
No

Do you have certified trainers on staff? (collection, BAT, STT)

Yes
No

Are you a member of a national drug testing, drug prevention organization such as DATIA?

Yes
No

Will you participate in an annual audit of your testing as part of our program?

Yes
No

Do you provide EAP services?

Yes
No

Has the applicant or any entity that controls the applicant, or any owner, partner, officer or director ever been convicted of, or is the applicant, or any owner, partner, officer or director currently charged with, committing a crime, whether or not adjudication was withheld?

Yes
No

“Crime” includes a misdemeanor, felony or a military offense. You may exclude misdemeanor traffic citation and juvenile offenses. “Convicted” includes, but is not limited to, having been found guilty by verdict of a judge or jury, having entered a plea of guilty or no contest, or having been given probation, a suspended sentence or a fine.

Please include a written statement explaining the circumstances of the incident.

Please attach additional documentation

Drop files here or

Max. file size: 24 MB.

Licenses, Certifications and Accreditations – Please provide copies of all licenses and certifications (including, but not limited to, federal and state) and any accreditations
Memberships – Please attach a copy of any memberships the entity holds
Certified Financials for the past three years
Certificate of Insurance and Surety Bond
Please provide three professional references