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877.360.4636

Random Consortium (Small Businesses) $90.00

Company Information

Do you approve the $90.00 annual fee? *

Yes - $90.00

Company Name: *

Address *

Town/City *

State *

Zip Code *

Reporting Contacts

Contact Name: *

Title *

Email Address to Receive Order Confirmation *

Phone Number *

Email Address to Receive Drug Test Results *

Employees to be added into Random Consortium

Employee's Name: *

Last 5 degits of Social Security Number: *

DOT Agency? *

Add a pre-employment DOT drug screen? *

Yes - $55.00 (pre-employment DOT drug screen)

No (pre-employment DOT drug screen)

Would you like to add more employees? *

Yes

No

Employee's Name:

Last 5 degits of Social Security Number:

DOT Agency?

Add a pre-employment DOT drug screen?

Yes - $55.00 (pre-employment DOT drug screen)

No (pre-employment DOT drug screen)

Employee's Name:

Last 5 degits of Social Security Number:

DOT Agency?

Add a pre-employment DOT drug screen?

Yes - $55.00 (pre-employment DOT drug screen)

No (pre-employment DOT drug screen)

Employee's Name:

Last 5 degits of Social Security Number:

DOT Agency?

Add a pre-employment DOT drug screen?

Yes - $55.00 (pre-employment DOT drug screen)

No (pre-employment DOT drug screen)

Need a DOT drug and alcohol testing policy? *

Yes - $250.00 (You will receive a call from our screening consultant, and we will create a customized policy for you.)

No (DOT drug and alcohol testing policy)

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