ASTS Corporation

Client Setup Sheet
Please fill out the Client Setup Sheet completely before you submit to ASTS. A confirmation email will be sent to the email address that you have supplied in the Clinic Information area once we have received your request. If you do not receive a confirmation email, please contact our office at 800-477-3177.

*Client Type:

New Client Setup Update Client Information

*Company Name:

Date:

*Address:

*City:

*State:

*Zip Code:

1st Contact:

Email:

Phone:

Ext:

Fax:

2nd Contact:

Email:

Phone:

Ext:

Fax:

*Services (Check all that apply — at least one)

DOT Non-DOT MRO ALL MRO Positive Only (Non-DOT)

*Results Delivery Via

Email Secured Fax Call & Mail Call & Fax Mail Only

Random Selections

Number of employees for random pool:

Please attach employee list:

IF NON-DOT

Percentages - Drugs: Alcohol:

Frequency: Quarterly Monthly

Random List Delivery Via

Email Secured Fax Mail

Comments

Clinic Information (must be completed in full)

Submitted By* :

Phone Number* :

Clinic Location* :

Your Email Address* :

Verification - Enter the code as shown

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