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Attachment G <br />Striving to be Drug Free <br />for a Safe Industry <br />BCRC ADMINISTRATOR INC. <br />BCRC MEMBER APPLICATION FORM <br />PHONE : (219)764-9500 FAX: (219)764-9505 <br />**PLEASE MAKE COPIES AS NEEDED** <br />DRUG/ALCOHOLTESTING NOTIFICATION <br />'Me following form is to be utilized when sending a Donor/Employee for <br />Post-Accident/Incident Drug Test, Probable Cause Drug Test and Alcohol <br />Test. The DER/Supervisor is to take the Donor/Employee along with this <br />form and valid picture identification, and present the above items at the time <br />of his/her arrival at the collection site. <br />Company <br />Company Telephone # <br />Requested by DER/Name <br />Location Accident Took Place: <br />Donor/Employee Name: <br />Driver's License # or BCRC# <br />Date of Test: <br />Time of Test: <br />Test Reason: (lease check <br />Date of Injury: <br />Post-Accident/Incident Testing <br />Probable Cause Testing <br />Please Test for Both: (lease check <br />Drug and Alcohol <br />Email to info@bcrcnet.com or Fax directly to BCRC r+ (219) 764-9510 <br />63 <br />