Personal information User name: Confirm user name: Password: Confirm password: First name: Last name: Company: Address: City: State: Zip: Phone: EMail:   Payment information Credit card type: -- Select value -- Visa Master Card American Express Credit card number: CVC/CVV2: Expiration date: -- Select value -- January February March April May June July August September October November December -- Select value -- 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020   Use the same address as above Address: City: State, Zip:		Optional information Company Contact for Collections Number of collectors on staff What are your fees for urine specimen collections? Do you conduct breath alcohol testing? N/A Yes No If "Yes", what instrument do you use for this testing? What is your fee for conducting breath alcohol testing? Is there an additional charge to confirm positive screens? N/A Yes No If "Yes", how much is the charge? Do you conduct saliva alcohol testing? N/A Yes No What are your fees for conducting saliva alcohol tests? Is there an additional charge to confirm positive screens? N/A Yes No If "Yes", how much is the charge? Do you conduct on-site testing devices for alcohol and/or drugs tests? N/A Yes No If "Yes", what types of on-site testing devices are your staff trained to conduct and your fees for conducting on-site testing devices, including the kit? Do you conduct on-site collections? N/A Yes No What are your fees for this service? Do you conduct after-hours/emergency collections? N/A Yes No Is there another contact name/number for this service? What are your fees for the after-hours collections?