Requester's Name *

(Name of person filling out form)

First Name

Last Name

Requester's Phone # *

(###)

###

####

DONOR D.O.B *

MM

DD

YYYY

DONOR PHONE# *

(###)

###

####

METHOD OF TESTING *

URINE

HAIR

BLOOD

DOES NOT APPLY

Type of Test *

Standard

instant (available for 5 or 10 panel URINE only)

INVOICE OPTION *

(First Initial test must be paid Up front and A card must be on file if you want to get monthly invoicing)

I HAVE AN ACCOUNT ALREADY/ INVOICE ME 1ST OF MONTH

PAY INVOICE NOW

CREATE AN ACCOUNT (card must be on file & first Initial test should be paid for up front)

I HAVE A CREDIT I WANT TO APPLY

IS THIS FOR DOT? (Department of Transporation) *

YES DOT

NO NON-DOT

IF DOT, WHAT MODE?

FMCSA

FRA

FTA

USCG

PHMSA