Drug & Alcohol - Occupational Testing Services      Data Sheet

Contact Name: (First and Last Name Please) __________________________________________________

Company name (If Applies) _______________________Address:__________________________________________

Do you have several testing sites ____Yes ____ No If yes to the (Several testing sites) give the location(s) : If more space is needed for this area, use a separate sheet of paper and submit with this form. _____________________________________________________________________________________________

Main Office Numbers Phone: (           )________-___________ Fax: (           )________-___________ 

Email:   _____________________________________ Web Site: _______________________________________

Can you do:

DOT drug Testing (urine collections): ___Yes ___No      DOT Alcohol Testing  ___Yes ___No

A one time non refundable Data Entry/Networking Fee of  $65.00 will set you up in our data base for Companies to find you or when we are called upon for Technicians/Collection Sites/Clinics/TPA's, ect;

PAYMENT TYPE   check one  ___ Visa   ___ Maser Card  ___ Discover  ____ American Express    ____Personal Check  ___ Money Order  

Paying by check/Money Order      Make payable to:  Tammy Hartman

Card Numbers _______________________________________ Expiration Date _______/____________

Print The Name that appears on the front of the Credit Card _____________________________________

Authorized Signature __________________________________ Date ____________________________

MAIL OR FAX BACK YOUR DATA SHEET TO:

Hartman 1155 Union Flat Rd.  Shelocta, Pa 15774

Phone: (724)726.0230    Fax : (724)726.0218

The data you submit will be shared with companies from all over the United States and Canada, by faxing/mailing your data, you are giving us permission to share your information via the web, phone or hard copy to and for Independent Contracting purposes. This is not a binding contract between you and T.  Hartman

Notes: