Drug and Alcohol Testing Programs to Meet Federal Requirements
National Headquarters
6265 Sepulveda Blvd.
Van Nuys, CA 91411
800-243-7669 | 818-779-1900
Fax 818-779-1908
Client No.
,
A.
Drug and Alcohol Program Manager
B.
City Permit Number
C.
City Permit Expiration Date
D.
Drivers License
E.
Start Date of Anti-drug Program
F.
Fee Paid $
F.
Renewal Fee Paid $
G.
Date of Drug Program Certification Expiration
G.
Date of Certification Expiration
H.
Date of Last Urine Drug Test
I.
Date of Alcohol Test
To Whom It May Concern:
Receipt of payment
for testing as part of compliance in an Anti-Drug Testing and Alcohol Misuse Prevention Program to
Authorized Medical Review Officer
