Drug & Alcohol Testing Enrollment Form

Call us toll-free at (877) 340-6101 to help enroll you in the program that fits your needs.

Enrollment Form

Please provide as many details as possible to help us better address your needs.

Company Name:

Alias:

Street Address:

Additional Street Addresses:

Phone Number:

Fax Number:

Email Address:

Authorized Contacts:

Number of Employees:

Type of Industry:

Government Regulated

Private

If you do not have a substance abuse policy, do you need assistance with the development of one?

Yes

Please indicate if the reporting destination details are different from those you already entered above by typing "same."

How would you like to receive test results?

Secure Fax

Mail

Secure Results Portal

Secure Fax Number:

Email Address:

Please indicate if the billing details are different from those you already entered above by typing "same."

Street Address:

Contact Person:

Phone Number:

Fax Number:

Email Address:

Secure Results, LLC

Warrington Greene

1432 Easton Road

Suite #3C

Warrington, PA 18976

Fax: (888) 900-8379