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:
Breath Alcohol
Drug (Urine)
Drug (Oral Fluid)
CDL Physical
Regulatory Agency
FMCSA
FTA
NON-DOT
PUC
FAA
PHMSA
USCG
FRA
DIRECT OBSERVATION
YES
NO
