D.O.T MEDICAL EXAMS

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CALL: 323-780-1650

Registration Form

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Owner OperatorCompany

Career Type
DOT-FMCSA (vehicle over 26,001 lbs.)PUC (16 or more passengers)Forensic (Non-Commercial License)PUC (less than 16 passengers)

Services Needed
Drug TestingAlcohol TestingRandom ProgramPhysicalSupervisor TrainingDrug & Alcohol Educational ClassDrug & Alcohol PolicyOther

Drug test results should be (Mark one):
FaxEmailPick-up in person

Company Name:
Dba:
DOT#:
MC#:
CA#:
PUC/TCP#:
Mailing Address:
City:
State:
Zip Code:
Company Phone:
Company Fax (Secured):
Company Phone:
Company Fax (Secured):
Company Email (For Results ONLY):
1st Contact Name:
1st Cell Phone:
1st E-mail Address:
2nd Contact Name:
2nd Cell Phone:
2nd E-mail Address:
3rd Contact Name:
3rd Cell Phone:
3rd E-mail Address:
Date:
Company Representative Signature: