EPASS Request

Today's Date(Required)

Month

Day

Year

Type of Testing(Required)

DOT

Non-DOT Testing

Company(Required)

Employee Name (Last, First)(Required)

Date of Birth(Required)

Employee Driver's License Number(Required)

State Issued(Required)

Employee Phone Number(Required)

Employee Email(Required)

Reason for Test(Required)

Pre-Employment

Random

Reasonable Suspicion/Cause

Post-Accident

Return to Duty

Follow-up

Other

Type of Test(Required)

Drug

Alcohol

Both

Send to Driver(Required)

Text to phone

Email

Don't notify driver

Test Location (Zip Code, City, State)(Required)

D.E.R. Email(Required)

Name

This field is for validation purposes and should be left unchanged.

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