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Customer Service 1-877-753-7663
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Required Customer Information For Account Set Up
Customer Name :
Corporate Address:
Designated Employee Representative (DER) Information
Alternate Contact Information
Name:
Name:
Phone:
Phone:
Fax:
Fax:
Email:
Email:
DOT Tests Information
Non-DOT Tests Information
DOT#:
What panel do you want run for Non-DOT tests?
# of DOT Employees:
# of Non-DOT Employees:
# of annual DOT tests estimated:
# of annual Non-DOT tests estimated:
Random Tests Information:
Will your company be doing Random Testing? If so, what is your preferred Random Testing Schedule?
Monthly
Quarterly
CCFs Information:
Will Chain of Custody Forms be stored at your facilities?
Yes
No
If yes, how many forms will you need?
What address should they be sent to?
FYI, it will take about 3 weeks for the forms to be printed and shipped.
Comments/Remarks:
Please send following Attachments to CSS Implementation.
1. Please prepare list of all company locations with address, phone number, and contact person. . (You may use a separate Excel spreadsheet or any other format you wish to send this information).
2. Please list your current clinics with address, phone, and contact person. If you have special pricing in place with any of these clinics please provide that as well. Please indicate number of Chain of Custody forms needed for each clinic. (You may use a separate Excel spreadsheet or any other format you wish to send this information).
3. Please provide a list of all employees needing access to the Compliance Safety Systems web site, including level of access, location they belong to and email address. (You may use a separate Excel spreadsheet or any other format you wish to send this information).
