Employer Authorization Form

Employer Authorization Form - _____ 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: Employer information der/company contact for results and/or physician call: 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. This includes citizens and noncitizens. Web employer:_____ date of birth:

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

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: _____ 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 You will need to apply for an ead if you: Web employer authorization form name and title (please print) signature: It is important that you write the correct eligibility category on your application. Web employer:_____ date of birth: This includes citizens and noncitizens.

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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: _____ 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. It is important that you write the correct eligibility category on your application.

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