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A Chance to Change Drug and Alcohol Testing, LLC

200 S. Elk St. Sandusky, MI 48471 P:(810)648-9144 F: (810)537-5033

243 E. Huron Ave. Bad Axe, MI 48413 P:(989)269-8362F:(989)269-8363

Name: Date of Birth:

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A Chance to Change Drug and Alcohol Testing, LLC to release my testing results to:

WHITE COPY . EMPLOYER PINK COPY . EMPLOYEE YELLOW COPY . CHANCE TO CHANGE

www.testingatCTC.com test@achance2change.net

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Please Check Desired Testing Option:

Oral Drug Swab - Collected and Sent Out to Laboratory

Background Check

Random

Pre-Employment

Post Accident

Suspicion

Other

Referring Agency Information: Date:

Name:

Address:

Phone: Fax:

Contact Email Address:

Authorizing Agent Signature:

Employee Information:

Reason For Test:

302 N. State St Caro, MI 48723 P:(989)286-3700 F:(989)286-3201

Drug Screen - Completed at Chance to Change

Drug Screen - Collected and Sent Out to Laboratory