Name *

First Name

Last Name

Phone *

(###)

###

####

Is the email for RESULTS same as above? *

Same As Above

NO

Are there any policy specifics our collector should know about? *

No (Collector can do their standard process)

Yes, I have policy specifics (please include below)

Does your policy exclude THC/ MARIJUANA? *

REMOVE THC ON TEST

KEEP THC ON TEST

Start Date of collection *

MM

DD

YYYY

End Date of collection

MM

DD

YYYY

Time of collection *

(In your time zone, disregard eastern time if you are not eastern)

Hour

Minute

Second

AM PM

IS THIS A COLLECTION ONLY?

(I have my own material, CCF & Lab)

COLLECTION ONLY

FULL SERVICE

Panel(s) to be Tested *

5 Panel

7 panel

10 Panel

5 Panel DOT (DEPT OF TRANSPORTATION)

Other

Method of Testing? *

Urine

Other

Select the following *

STANDARD TEST (No same day results)

INSTANT/RAPID (only non-negatives get sent out to lab for confirmation, available for 5 or 10 panel)

DOT (DEPARTMENT OF TRANSPORTATION)

OBSERVED

Full address for site location *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

ONSITE CONTACT PERSON:

First Name

Last Name

Phone

(###)

###

####

WOULD YOU LIKE A CALL BACK? *

YES

NO

Shortly after receiving this information from you, we will send you an agreement to be signed along with an invoice for upfront payment. *

I agree