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Substance Abuse

"*" indicates required fields

Company Name

Contact Name

First Last

Contact Email

Contact Phone

Which CCS testing administrator is processing your test results?

If you have not chosen a CCS Third Party Administrator please follow this link? https://ccs-safety.org/wp-content/uploads/2021/04/TPA-List.pdf

Billing Address*

Street Address Address Line 2 City State ZIP Code

CCS Cards will be mailed to this mailing address.

Same As Above

Same as above

Mailing Address*

Street Address Address Line 2 City State ZIP Code

List of Employees

Name	Last 6 of Social Security Number	Date of Birth	Actions

There are no Employees.

Unique ID