Independent Collector Partnership Application
Please complete the information below.
Name
*
First Name
Last Name
Company Name
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Website
*
Social Media (Select all that apply)
*
Facebook
Instagram
Google Profile
Collection Certifications
*
DOT
DNA
Oral Fluid
Hair Follicle
BAT
Other
If yes, which labs are you set up with?
*
Labcorp
Quest
CRL
DDC
Alliance DNA
Other
Services Offered (Select all that apply)
*
DNA Collection
Employer Drug Testing
Phlebotomy
Fingerprinting
Other
Collection Options
*
Mobile
Physical Location
Both
How many years of collection experience?
*
0-1
2-5
5+
What state(s) do you service?
*
Do you have Professional/General Liability Insurance?
*
Yes
No
Upload COI (Certificate of Insurance)
Browse Files
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Choose a file
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What is your availability?
*
Weekdays
Evenings
Weekends
On-Call
Please provide any additional comments or details:
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