Employer Authorization Form

Employer Authorization Form - You will need to apply for an ead if you: Preventing discrimination we provide information on employee rights and preventing discrimination in the workplace. Employer information der/company contact for results and/or physician call: It is important that you write the correct eligibility category on your application. _____ work related physical examination t injury t illness t preplacement t baseline t annual t exit date of injury_____ dot physical examination breath alcohol special examination substance abuse testing This includes citizens and noncitizens. Web employer:_____ date of birth: Web employer authorization form name and title (please print) signature:

_____ work related physical examination t injury t illness t preplacement t baseline t annual t exit date of injury_____ dot physical examination breath alcohol special examination substance abuse testing It is important that you write the correct eligibility category on your application. You will need to apply for an ead if you: Employer information der/company contact for results and/or physician call: This includes citizens and noncitizens. Web employer:_____ date of birth: Preventing discrimination we provide information on employee rights and preventing discrimination in the workplace. Web employer authorization form name and title (please print) signature:

You will need to apply for an ead if you: Web employer:_____ date of birth: Employer information der/company contact for results and/or physician call: It is important that you write the correct eligibility category on your application. This includes citizens and noncitizens. _____ work related physical examination t injury t illness t preplacement t baseline t annual t exit date of injury_____ dot physical examination breath alcohol special examination substance abuse testing Web employer authorization form name and title (please print) signature: Preventing discrimination we provide information on employee rights and preventing discrimination in the workplace.

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Web Employer:_____ Date Of Birth:

It is important that you write the correct eligibility category on your application. Employer information der/company contact for results and/or physician call: You will need to apply for an ead if you: This includes citizens and noncitizens.

_____ Work Related Physical Examination T Injury T Illness T Preplacement T Baseline T Annual T Exit Date Of Injury_____ Dot Physical Examination Breath Alcohol Special Examination Substance Abuse Testing

Web employer authorization form name and title (please print) signature: Preventing discrimination we provide information on employee rights and preventing discrimination in the workplace.

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