Collector Name *

First Name

Last Name

All Services you offer *

DOT Testing

Non DOT Testing

Hair

Urine

Breath Alcohol

Blood

Select all that applies *

Collection only (using PRECISION ccf account & lab)

Full service (using your own lab & ccf)

24-hour walk-in

24-hour on-site

Late night hours

Regular business hours

On-site fee is which of the follwoing

Per Hour

Flat Rate

Other (Please detail below)

(If any hourly fee(s), when does the hour begin?) *

When we reach the location

The moment we start heading to the location

Doesn't apply

Other (detail below)

Select your payment methods *

(you can choose all that apply)

We can bill you

We take upfront debit/credit over the Phone

you can mail a check

Other

My client should not be asked about making a payment or anything regarding the payment information. Prior to any collection you may be given our company forms, Chain of custody, and any other material that we may need to supply you. The exchange of any information outside of our company is prohibited and as a collector representing us, you agree to faithfully and to the best of your ability carry out the duties and responsibilities communicated by Precision Mobile Lab Testing LLC. *

I Agree

Full name of the person filling this form: *

First Name

Last Name