WELCOME TO THE CRG ONLINE SERVICE REQUEST PORTAL Name* First Last Employer/Company Name* If services are not for a specific employer or company, please enter SELFDOB* Month Day Year Email* Cell Phone*6 Digit Security PIN* Security pin will be required for customers to open protected documents, such as exam or test results, provided to you via email.Tell us where would you like to go for these services? Preferred City/State/Zip* We will do our best to schedule your services as close to your desired location as possible using Network Providers. Depending on current location and the services requested, clients may be required to travel to a Network Provider not in close proximity to their current location.Purchase Options: FMCSA Driver Fitness For Duty Examination (DOT Physical) - $95.00 Basic Non-DOT Physical Examination - $95.00 DOT Drug Screen - $75.00 5 Panel Non-DOT Urine Drug Screen - $65.00 10 Panel Non-DOT Drug Screen - $75.00 10 Panel w/Extended Opiates Non-DOT Urine Drug Screen $80.00 DOT Breath Alcohol Test - $60.00 Non-DOT Breath Alcohol Test - $60.00 HiddenAgency TypeAgency Type*-select-Federal Aviation Admin (FAA)Federal Motor Carrier Safety Admin (FMCSA)Federal Railroad Admin (FRA)Federal Transit Admin (FTA)Pipeline & Hazardous Materials Safety Administration (PHMSA)United States Coast Guard (USCG)HiddenCDLCDL #* State of Issuance*-select-ALAKAZARCACOCTDEFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWYHiddenSSN/ID#SSN / ID#* HiddenReason for testReason for test*-select-Pre-EmploymentRandomReasonable Suspicion/CausePost-AccidentReturn to DutyFollow UpOtherHiddenPricingFMCSA Driver Fitness For Duty Examination (DOT Physical) Price: Basic Non-DOT Physical Examination Price: DOT Drug Screen Price: Product 5 Panel Non-DOT Urine Drug Screen Price: 9 Panel Non-DOT Drug Screen Price: DOT Breath Alcohol Test Price: Non-DOT Breath Alcohol Test Price: 10 Panel w/Extended Opiates Non-DOT Urine Drug Screen Price: Consent* I agree to the following:*I acknowledge that CRG will attempt to schedule services as close to the Preferred location as possible using Network Providers and that payment for scheduled services is non-refundable. I understand that scheduled services must be completed within 2 weeks of the service request date. I acknowledge that CRG will send protocol for the services requested, including the location of the Network Provider and required e-passports, using the email provided within 24 business hours of payment.I acknowledge that a copy of my exam or test results will be provided to me either at the time of service or after testing is complete. Transmission of result data occurring after the time of service will occur via email and reports can only be accessed using the 6 digit security code provided during my registration.Credit Card* American ExpressDiscoverMasterCardVisaSupported Credit Cards: American Express, Discover, MasterCard, Visa Card Number Month010203040506070809101112 Year20222023202420252026202720282029203020312032203320342035203620372038203920402041 Expiration Date Security Code Cardholder Name Total $0.00 Billing Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Billing Email* Enter Email Confirm Email By clicking submit I agree to the terms and conditions CAPTCHANameThis field is for validation purposes and should be left unchanged.