Request eCCF

To request an electronic control custody form, please provide the information on the driver below. Once the electronic form is completed, you will receive an email with the confirmation that you can print and have your driver take to the clinic.

Driver's Name *

Driver's CDL Number *

Test Location City *

Test Location State *

Test Location Postal Code *

Driver's Phone Number *

Email to Send Confirmation to *

Driver's CDL Issuance State *

Reason For Testing *