Drug and Alcohol Testing Program: Registration Form

Please fill out the form below. All fields marked with an asterisk are required. This email address will be used for receiving your confidential test results.

Your Contact Details

Company Name:*

Billing First Name:*

Billing Last Name:*

Primary Contact:*

(Person to receive Test Notification and Results)

Alternate Contact:

Billing Address:*

City:*

State:*

Zip Code:*

Phone:*

Fax:

Email:*

Preferred Invoice Delivery:* Email US Mail

Where did you hear about Labworks USA?:

If "other." please describe

Driver Information

Driver Name	CDL Number	Driver State	Pre-Employment Test *
			Already on File and Available for Inspection Please send a Pre-Employment Test Form

Driver Name

CDL Number

Driver State

Pre-Employment Test *

Already on File and Available for Inspection

Please send a Pre-Employment Test Form

Supervisor Training Certification Course

The Supervisor Training Certification Course costs $55. One person from each company with direct driver contact is required to be trained as a supervisor in order to fulfill the DOT requirements. If you have a valid Supervisor Certification, then it is not necessary to sign up for this.

Supervisor Name

Annual Membership

Supervisor Training Certification Course

$55.00

$0.00

Enrollment of company and first driver in the Labworks USA Consortium

$49.95

Additional Drivers

$25.00

$0.00

Total:

$49.95

View and Print Terms and Conditions

I have read the terms and conditions below and indicate my acceptance of them by entering my initials here:*

Any special instructions when processing your application?

Pay with Credit Card

Online Payment Service

Card Number:*

Expiration Date:*

CVV:* (3-digit security code on back of card)

Pay via Telephone

If you would like to pay by phone or arrange credit terms call 888-582-8001.

Note: Your order will remain on hold until payment arrangements are complete.