*AI*******DV*

AI*******DV

ePassport™

For Donor Use:

Clinic Information: MAP

Concentra Medical Center - Richmond

**** ******* **** **

STE 203

RICHMOND,CA 94806

ph #:510-***-****

Fax: 510-***-****

DON'T FORGET!

- Take ePassport and Photo ID

- All other documents provided by employer

- Call clinic to confirm their hours of service

Scheduled Time: Between 7/31/2014 12:28:00 PM CST and 8/5/2014 12:28:00 AM CST

For Clinic Use: *Use eScreen Scheduled Event Account*

Scan the ePassport barcode into eScreen123.

Scheduled Event Details will appear.

Confirmation #: AI9769603DV

Regulation: NON-DOT Donor Information

Reason for Test: Pre-employment Jason Garner

Name:

Services to be performed:

eCup

913962-405

eScreen Acct #:

WASTE MANAGEMENT - WMI

Employer or

Corporate Office

Agent Name:

Additional Requirements/Notes:

Bill services to :

eScreen, Inc.

PO Box 25902

Overland Park, KS 66225

Contact eScreen Client Services with questions: 800-***-**** opt. 5

Contact this candidate