Name *

First Name

Last Name

Do you have an account with us that include chain of custody orders?

Yes I have an account that includes chain of custodies

No, I do not

Supplies Needed? *

(You may select more than one)

CHAIN OF CUSTODIES

LAB CUPS

FEDEX LABELS

FEDEX BAGS

NEITHER APPLIES

Where should we send them? *

Address on account file

Send to another address

Is the physical address different from the mailing address? *

(If so, please provide the physical address below to additional notes)

YES

NO

Address to send them to, if not on file:

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country