Drug & Alcohol Test and Medical Cert Request Form Please enter your name:(Required) First Last Enter your email address(Required) Select your location:(Required)Please selectCarrollCedar RapidsDes MoinesDubuqueKansas CityLas VegasLincolnOrlandoPhoenixRockfordSaint LouisSioux FallsPlease select(Required) Drug and/or Alcohol Test Medical Certificate BOTH What are we sending the driver for?(Required) DOT Medical Certificate Drug and/or Alcohol Test BOTH Carroll - What would you like to complete?(Required) Drug and/or Alcohol Test DOT Medical Certificate Pre-Employment Physical Enter the name of the individual that will be taking the test/medical(Required) First Last Please add the City, State, Zip Code for the location of the test(Required) City State / Province / Region ZIP / Postal Code Enter the estimated date to be completed?(Required) MM slash DD slash YYYY DOT or Non-DOT Test?(Required) DOT - for drivers DOT FTA - for 380 & VIA drivers Non-DOT - for employees that do NOT drive Type of Test(Required) Pre-Employment Random Follow-Up Test For any other types of tests, a phone call must be made before the test is conductedPre-Employment Test Information(Required) Drug Test Only Random Drug Information(Required) Drug Test Only Alcohol Test Only BOTH Drug and Alcohol Test List any special circumstances for the test (must be on a Saturday; request for a specific location; etc)Send the driver to the clinic that we have set-up for DOT medicals for your location. A copy of this authorization will be sent to Payables.Submit this form and the authorization for the Drug/Alcohol Test and/or DOT medical certificate will be emailed to you. Once you receive this, provide to the driver so they can take it with them to the facility.You must call Soppe's and make an appointment, they will receive a copy of this authorization when it is submitted. A copy of this authorization will be sent to Payables.
