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* MM DD YYYY 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 Agency 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)CDLCDL #*State of Issuance*-select-ALAKAZARCACOCTDEFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWYSSN/ID#SSN / ID#*Reason for testReason for test*-select-Pre-EmploymentRandomReasonable Suspicion/CausePost-AccidentReturn to DutyFollow UpOtherPricingFMCSA Driver Fitness For Duty Examination (DOT Physical) Price: $95.00 Basic Non-DOT Physical Examination Price: $95.00 DOT Drug Screen Price: $75.00 Product 5 Panel Non-DOT Urine Drug Screen Price: $65.00 9 Panel Non-DOT Drug Screen Price: $75.00 DOT Breath Alcohol Test Price: $60.00 Non-DOT Breath Alcohol Test Price: $60.00 10 Panel w/Extended Opiates Non-DOT Urine Drug Screen Price: $80.00 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 ExpressDiscoverMasterCardVisa Card Number Month010203040506070809101112 Year20202021202220232024202520262027202820292030203120322033203420352036203720382039 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 FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin 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 conditionsCAPTCHANameThis field is for validation purposes and should be left unchanged.