Independent Collector Partnership Interest Form
Please complete the form with accurate details about your collection services and certifications. CJB Compliance Solutions will manage your compliance requirements, including random selections, notifications, and recordkeeping.
Section 1: Company Information
Full Name
*
First Name
Last Name
Company Name
*
Company Name
DBA (if applicable)
Business Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Contact Details
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Company Information
Website/Social Media Profiles
Facebook
Instagram
Google Profile
Collection Certifications
*
DOT Urine
Breath Alcohol
DNA
Saliva
Hair Follicle
None
Do you have lab accounts set up already?
*
Yes
No
Services Offered
*
DNA Testing
Drug Testing
Phlebotomy Services
Fingerprinting
Collection Options
*
On-Site
Mobile
Both
Do you have liability insurance?
*
Yes
No
Pleas provide any additional comments or details.
Agreement
*
I understand enrollment is not finalized until confirmed by CJB Compliance Solutions.
Submit
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