Client Test Authorization Form

What is the reason for the test?

Quick tips on filling out this form

DOT Testing
If you need to authorize a Department of Transportation test, please ensure the employee has a valid CDL or permit.

Non-DOT Testing
If you are wanting to authorize any test not required by federal regulations.

(*) All fields are required unless otherwise indicated.

What is the reason for the test? *

Pre-Employment

Random

Return To Duty

Follow Up

Other

Test Authority *

DOT Testing

Non-DOT Testing

If Pre-Employement DOT Test, who is performing pre-employment query in Clearinghouse? *

Company

CleanFleet

Not DOT Pre-Employment Test

Test Type *

Drug Test Only

Alcohol Test Only

Drug and Alcohol Test

Company Name *

Company Representative Requesting Test *

Donor Name, First and Last *

Donor Driver License Number and State *

Donor Birth Date *

Employee Phone Number *

What day would you prefer the donor to test? *

Current Location of Donor (City and State) *

How would you like CleanFleet to contact your company regarding this test? *

Additional contact information or questions (optional)