Certified Driver's Receipt for NON-DOT Drivers

Certified Driver’s Receipt for NON-DOT Drivers

Collection Site (Louisville Area):
Carriers Concepts, LLC
2147 Buechel Bank Road
Louisville, Ky 40218

Laboratory:
Clinical Reference Labs
11711 W. 83rd Terrace
Lenexa, KS 66150

Medical Review Officer (MRO)
Doctors Review Service
546 Franklin Ave.
Massapequa, NY 11758

I have read and fully understand the for mentioned items in this Drug and Alcohol Policy for NON-DOT drivers, By signing below, I understand that I may be REMOVED from my driving position, if found that I have NOT complied with program.

Name(Required)

First Last

Signature(Required)

Date(Required)

Witness Name: ________________________________
Witness Signature: _____________________________ Date: _________________________