SATOP Screening Payment

SATOP Screening Payment
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
E-mail Address*
example@example.com
Date of Birth*

MonthDayYear
Date

SATOP SCREENING FEE*

SATOP ScreeningChoose this if this is your first SATOP screening since your most recent DWI arrest.

$386.15

SATOP Screening - Expired ScreeningChoose this if you have already taken a SATOP screening since your most recent DWI, and that screening was done more than 6 months ago.

$129.95

Total

$0.00

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

By submitting this payment I understand and accept to receive communications from Midwest ADP via e-mail, text message, fax, phone and/or postal mail, and that these communications may include confidential information about my SATOP treatment.
Total Paid
Date Submitted

MonthDayYear
Date
Should be Empty: