Clone of OccuMedX Drug Test Account Setup

Toxicology Services Agreement
Company Information

Please enter your company contact and Direct Employer Representative information below.
Which Gilbane project are you registering for?
Client Company Name*
Billing Contact Name*

First NameLast Name
Billing Contact Email Address*
example@example.com
Billing Address*

Street Address

Street Address Line 2

CityState / Province

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Billing Phone Number*
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Result Reporting Information

A Direct Employer Representative, DER will receive drug testing results via our online portal. Please enter the contact information below to receive login information and drug test results.
Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.

Terms and Fees

Gilbane Building Company has selected OccuMedX Group, Inc. to administer the Drug and Alcohol Testing Program for certain projects. By signing and dating this form, you agree to accept the services and abide by the terms and conditions listed in the exhibits attached hereto.
Exhibit A - Pricing Schedule
Exhibit B - Terms and Conditions
● Fees are outlined in the EXHIBIT A above.
● OCCUMEDX will invoice CLIENT directly for the services. Invoices will be issued monthly. Payment terms are net thirty (30) days. Late fees will apply to outstanding charges and shall accrue at the rate of 5% per month on payments that are not received within 5 days of due date. If you fail to pay for any invoice when it becomes due, OCCUMEDX may decline further service until you have paid the outstanding charges.
● CLIENT agrees to pay all costs associated with the collection of any unpaid balances from you, including reasonable attorney's fees.
● This agreement sets for the entire understanding between CLIENT and OCCUMEDX concerning the subject matter herein. Any modification of this Agreement must be made in writing and signed by both parties. You agree that this Agreement will be construed and governed by the laws of the State of North Carolina, excluding rules of governing conflicts of law. You agree that any lawsuits pertaining to this Agreement shall be brought in the federal or state courts in the State of North Carolina
Acceptance
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Toxicology Services Agreement

Company Information

Result Reporting Information

Terms and Fees

Exhibit A - Pricing Schedule

Exhibit B - Terms and Conditions

Acceptance