EV Screening & Compliance — Collection Site Partner Application

EV Screening & Compliance — Collection Site Partner Application

Provide your business, service capabilities, and proposed rates to apply for partner review. No application fee—approval isn’t guaranteed.
Business Information
Legal Business Name
DBA / Trade Name
Primary Contact Name

First NameMiddle NameLast Name
Business Email
example@example.com
Business Phone
Please enter a valid phone number.Format: (000) 000-0000.
Website URL
Physical Collection Site Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Additional States and ZIP Codes Served
Business Type
Number of Locations
Services Offered
Services Offered

Other
Specify Other Service
Panel Types

Other
Specify Other Panel Type
Accept Walk-Ins?
Accept Appointments?
Operating Days and Hours
Offer Mobile Services?
Mobile Service Travel Radius
Minimum Callout Fee
Pricing
Requested collection-only fee per donor (USD)
Rapid screening service fee per donor (USD)
Mobile visit / travel fee (USD)
Additional fees or pricing details
Operations and Compliance
Willingness to use EV-approved cups and collection materials
Willingness to follow EV-approved collection, documentation, specimen shipping, and reporting instructions
Ability to securely submit screening results online
Relevant collector training and certifications
Business liability insurance in place
Applicable licensing and authorizations
Upload proof of insurance and collector qualifications

Cancelof
Acknowledgments
I confirm that the information provided in this application is accurate and complete.
I understand that the independent contractor relationship is subject to review and a written agreement, there is no guaranteed volume, and EV will contact us if selected.
I permit EV to contact us using our business email and/or business phone number provided in this application.
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EV Screening & Compliance — Collection Site Partner Application

Business Information

Services Offered

Pricing

Operations and Compliance

Acknowledgments