Drug Free Discounts Form Please tell us about you and your companyYour Name: Company Name: Federal Employer ID #: Mailing Address: City, State, Zip: County: Email Address: Phone #: Fax #: Approximately how many employees do you have? Does your company have an Employee Assistance Program?NoYesIs your company subject to Federal Grants or Contracts?NoYesWould you like to conduct random testing?YesNoHow did you hear about us? Insurance InformationYour Insurance Agent's Name: Insurance Agency: Lab InformationPreferred Lab or Doctor's Office for Drug Testing: Lab Phone Number: Lab Mailing Address: Lab City, State, Zip: Δ