Independent Collector Partnership Interest Form
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 Urine
DNA
Saliva
Hair Follicle
None
Other
Do you have lab accounts set up already?
*
Yes
No
If yes, which labs are you set up with?
Labcorp
Quest
CRL
DDC
Alliance DNA
Other
Services Offered (Select all that apply)
*
DNA Testing
Drug Testing
Phlebotomy Services
Fingerprinting
Other
Collection Options
*
On-Site
Mobile
Both
Do you have Liability Insurance?
Yes
No
Please provide any additional comments or details:
Submit
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