3RD PARTY DONOR FORM Precision Rep Name * (Your Name) Company Name * Does the company need to be invoiced? * I DID NOT PAY ATTENTION TO THIS SECTION SEND AN INVOICE FOR PAYMENT COMPANY PAID UP FRONT Is this for DOT? * NO YES THIS IS FOR DOT IF DOT WHAT IS CDL LICENSE # AND STATE (If applicable) DER Type of Test * REASON FOR TEST? * Pre-Employment Random Post-Accident Reasonable Suspicion Other Donor Name * First Name Last Name Donor D.O.B: * MM DD YYYY Donor Phone # (###) ### #### Drug Test cost: $ Select what applies * Collection Only Full service Breath Alc Cost: $ Onsite fee: $ TOTAL COST: * $ Email for results * TPA SECTION TPA Company Name: * TPA TOTAL ESTIMATE: $ ADDITIONAL INFORMATION Thank you!