Section 1 - Company
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Company (Employer):
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| Contact Person (DER): |
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| Title: |
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| Street Address: |
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| City: |
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| State: |
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| Zip: |
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| Phone: |
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| Fax: |
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| Email: |
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Section 2 - Results
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| Name (Results 1): |
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| Title (Results 1): |
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| Email (Results 1): |
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Name (Results 2):
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| Title (Results 2): |
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| Email (Results 2): |
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Section 3 - Billing
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Please Bill Me (Monthly - Net 14) |
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Billing Information (Same as Above) |
| Company (Billing): |
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| Contact Person (Billing): |
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| Title (Billing): |
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| Street Address (Billing): |
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| City (Billing): |
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| State (Billing): |
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| Zip Code (Billing): |
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| Phone (Billing): |
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| Fax (Billing): |
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| Email (Billing): |
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Section 4 - Drug Testing
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$44.95 5 Panel Laboratory |
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$49.95 10 Panel Laboratory |
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$49.95 DOT 5 Panel Laboratory & MRO
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$129.95 5 Panel Hair Follicle Laboratory |
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$54.95 5 Panel Laboratory with Alcohol |
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$59.95 10 Panel Laboratory with Alcohol |
Section 5 - Collection Network
Choose Quest Diagnostics or LabCorp or Both |
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Quest Diagnostics |
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LabCorp |
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Section 6 -
Alcohol Testing
DOT & Non-DOT |
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$49.95 Breath Alcohol Testing |
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Section 7 - On-Site Testing
Minimum 10 Employees
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$59.95 5 Panel On-Site Collection
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$64.95 10 Panel On-Site Collection
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$64.95 5 Panel DOT On-Site Collection
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Section 8 - Special Instructions
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| Special Instructions: |
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