Your Social Security Number (last 4 digits minimum requirement) *
Your answer
Reporting authority for your credentials *
Date of Violation (Positive Test or Failure to Report) *
MM
/
DD
/
YYYY
Reason stated on results for violation *
Reason you took that DOT test *
Have you had any prior Drug/Alcohol violations? *
Your Employer (or pre employment) Company Name at the time of the violation *
Your answer
Street Address for Company at time of Violation *
Your answer
Contact Name for employer at time of Violation (Usually the safety person who sent you for the test) *
Your answer
Email Address for Contact person noted above (safety person at employer at time of violation) *
Your answer
Please let me know how you found out about my SAP service (ex employer referred, friend referred, search engine etc . This is not required for reporting but is appreciated)