SELF RANDOM TESTING ORDER FORM SELF RANDOM TESTING ORDER FORM SELF RANDOM TESTING ORDER FORM REASON FOR TEST: RANDOM RANDOM Are you enrolled into our random program? * Yes I am enrolled to PMLT random program No, just scheduling test and using another random program Neither applies Name of person testing * First Name Last Name Date of birth * MM DD YYYY Phone * (###) ### #### Email * Zip code for testing: * Desired location (If any) (Location may not be available based on specific test) What time were you looking to go in? Hour Minute Second AM PM Are you responsible for payment? * I am using my test credit that I prepaid for I am responsible (pay invoice now) Charge card I added on file Other is responsible (a payment must be made before a test is scheduled) Last 4 digits of the card we should have on file (If applicable) Message In a few moments you will be receiving your barcode authorization which will include the address to where you will be testing. Provide the barcode to the facility when you arrive. * I Understand Thank you!