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Customer Account Setup
Company Name
Company Physical Address
Company Billing Address (if different than physical address)
Main Phone Number
Main Email Address
Type Of Industry
Type Of Industry
Designated Employer Representative (DER) Information
The DER is the person we will contact for: positive results
refusals
shy bladder
problems during collection
DER Name
DER Phone Number
DER Email Address
Billing Information
Please select How You would like us to bill your company:
Please select How You would like us to bill your company:
Pay Per Test (pay via link or phone for each donor)
Invoice Monthly
AP Email
AP Phone Number
Testing Authorization Method
Testing Authorization Method
CCF provided by employer
CCF provided by VNM Drug Screening
Walk-ins with employer authorization
Call/text/email authorization
I authorize VNM Drug Screening to perform drug and alcohol testing services for our company. I confirm that the Designated Employer Representative listed above is authorized to receive drug testing results and communications.
*
Signature
Name
*
Title
*
Submit
