White Glove Drug And Alcohol Testing, Inc.

WHITE GLOVE DRUG & ALCOHOL TESTING, INC. STATE OF MARYLAND COLLECTION REQUEST FORM

Hours of Operation Monday through Friday: 9:00 a.m. to 5:00 p.m. Saturday: 10:00 a.m. to 2:00 p.m. Office: 410-458-8276 Fax: 410-544-2111 Email: [email protected]

Agency Name: ______Agency Code: ______Collection Site: ______Site Code: ______Collection Site Address: ______

Preferred Date: ______Preferred Time: ______

Preferred Day (if any): _____Monday _____Tuesday _____Wednesday _____Thursday _____Friday _____First Available Date

ATR: ______TELEPHONE: ______EMAIL: ______FAX: ______ATR’s SIGNATURE: ______

Number of Employees (estimated): ______1-3 ______4-9 ______10+

Block Time: ______4 hours ______8 hours ______DPSCS (additional 30 minutes possible) ______Other

Onsite testing is CONFIRMED as scheduled for the agency and collection site indicated above on:

Date: ______Time: ______Signature: ______Revised 12/10/2012