Please fill out the form below completely.  You will be contacted via
email within 24 hours to notify you we are actively trying to schedule the
appointment and again once it is scheduled.  Thank you for your
business.
SELECT YOUR SERVICE
Pre-Employment
Screening:
 Ergonomic
Evaluation:
Job Analyses:
EMPLOYER INFORMATION
Company:
Job Title:
Contact Person:
Phone #:
Fax #:
EMPLOYEE INFORMATION
Name:
Address:
City:
 State:
 Zip:
Phone 1:
 Phone 2:
Is a translator needed?:
(If yes, please provide language)
SS #:
 DOB:
 Date of injury:
REFERRAL INFORMATION
Name:
Company:
Address 1:
Address 2:
City:
 State:
 Zip:
Phone #:
 Fax #:
Address report to:
CC report to:
Video sent to:
Date Needed:
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(Confirmation email will
be sent to this address)
BILLING INFORMATION
Name:
Company:
Address 1:
Address 2:
City:
 State:
 Zip:
Phone #:
 Fax #:
Claim #:
Email address:
ADDITIONAL INFORMATION
Please include any additional information, comments, or special
requests you would like addressed:
Your Industrial Solution
754 Stallion Drive
Auburn, PA 17922

Phone: 570.691.8986
Fax: 570.739.1228