Employer Authorization Form

Employer Authorization Form - Employer information der/company contact for results and/or physician call: 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 This includes citizens and noncitizens. Preventing discrimination we provide information on employee rights and preventing discrimination in the workplace. You will need to apply for an ead if you: It is important that you write the correct eligibility category on your application.

Preventing discrimination we provide information on employee rights and preventing discrimination in the workplace. Web employer:_____ date of birth: Employer information der/company contact for results and/or physician call: 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: It is important that you write the correct eligibility category on your application. You will need to apply for an ead if you:

It is important that you write the correct eligibility category on your application. Web employer:_____ date of birth: You will need to apply for an ead if you: This includes citizens and noncitizens. Employer information der/company contact for results and/or physician call: Preventing discrimination we provide information on employee rights and preventing discrimination in the workplace. _____ 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:

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Employer Information Der/Company Contact For Results And/Or Physician Call:

Web employer:_____ date of birth: Preventing discrimination we provide information on employee rights and preventing discrimination in the workplace. _____ 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.

Web Employer Authorization Form Name And Title (Please Print) Signature:

This includes citizens and noncitizens. You will need to apply for an ead if you:

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