PLEASE SELECT SERVICES REQUIRED

Please select services required:

Drug & Alcohol Testing Services *

Select Drug Screen Type(s): *

DOT

NON-DOT

BOTH

DOT MODE: *

How would you like Results/Reports sent? *

Secure Email

Secure Fax

Web Login

Custom Drug and Alcohol Policy Service *

Do have a policy in place? *

**DOT and most State laws require a drug and alcohol policy.

Random Selection Service *

Selection pool information *

Supervisor Training Services *

Employee Background Services *

Designated Employer Representative (DER)

DER Name: * 🛈

Last Four DER Social: *

DER Phone # *

DER Email Address: *

Will the DER be included in the Random Testing Pool? *

If "YES", Please ADD the DER as an employee in the form below.

Additional contact person (1)

Phone #

Email Address:

Additional contact person (2)

Phone #

Email Address:

Employee(s) to be added to random selection pool

** If you are adding more than 20 employees, please contact us for a seperate form **

Employee Name *

Employee SS# *

MODE *

Pre-Employment test date? 🛈 +

ADD More?

Employee Name *

Employee SS# *

MODE *

Pre-Employment test date? 🛈 +

ADD More?

Employee Name *

Employee SS# *

MODE *

Pre-Employment test date? 🛈 +

ADD More?

Employee Name *

Employee SS# *

MODE *

Pre-Employment test date? 🛈 +

ADD More?

Employee Name *

Employee SS# *

MODE *

Pre-Employment test date? 🛈 +

ADD More?

Employee Name *

Employee SS# *

MODE *

Pre-Employment test date? 🛈 +

ADD More?

Employee Name *

Employee SS# *

MODE *

Pre-Employment test date? 🛈 +

ADD More?

Employee Name *

Employee SS# *

MODE *

Pre-Employment test date? 🛈 +

ADD More?

Employee Name *

Employee SS# *

MODE *

Pre-Employment test date? 🛈 +

ADD More?

Employee Name *

Employee SS# *

MODE *

Pre-Employment test date? 🛈 +

ADD More?

Employee Name *

Employee SS# *

MODE *

Pre-Employment test date? 🛈 +

ADD More?

Employee Name *

Employee SS# *

MODE *

Pre-Employment test date? 🛈 +

ADD More?

Employee Name *

Employee SS# *

MODE *

Pre-Employment test date? 🛈 +

ADD More?

Employee Name *

Employee SS# *

MODE *

Pre-Employment test date? 🛈 +

ADD More?

Employee Name *

Employee SS# *

MODE *

Pre-Employment test date? 🛈 +

ADD More?

Employee Name *

Employee SS# *

MODE *

Pre-Employment test date? 🛈 +

ADD More?

Employee Name *

Employee SS# *

MODE *

Pre-Employment test date? 🛈 +

ADD More?

Employee Name *

Employee SS# *

MODE *

Pre-Employment test date? 🛈 +

ADD More?

Employee Name *

Employee SS# *

MODE *

Pre-Employment test date? 🛈 +

ADD More?

Employee Name *

Employee SS# *

MODE *

Pre-Employment test date? 🛈 +

Special Notes

Support

If you have additional questions or concerns, please feel free to contact us (406) 256-2037 or Email us at: Support@mtchemnet.com

Please note that with any changes you make to your account with us, you should recieve a response from our staff within (3) business days. If not, please contact us directly to verify your changes have been made.

COMPANY INFORMATION

PLEASE SELECT SERVICES REQUIRED

Designated Employer Representative (DER)

Employee(s) to be added to random selection pool

Support