Company Name

Company Location

HireRight Account Number

First Name

Last Name

Contact Email

Phone (enter phone number without dashes)

Name of Facility (To Be Shipped)

Shipping Phone Number (enter phone number without dashes)

Shipping Country Canada Puerto Rico United States

Shipping Address (Line 1)

Shipping Address (Line 2)

Shipping City

Shipping State AB AK AL AR AZ BC CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MB MD ME MI MN MO MS MT NB NC ND NE NF NH NJ NM NS NT NU NV NY OH OK ON OR PA PE QC RI SC SD SK TN TX UT VA VT WA WI WV WY YT

Shipping Zip Code

Choose Laboratory LabCorp Quest Alere Medtox CRL Psychemedics None/Unknown

Quantity Requested 10 25 50 100 200

Supply Type non-DOT DOT

Supplies Requesting (Please Select) Chain of Custody FormLab Based Urine Collection KitsShipping SuppliesSpecimen BagsOratect/T-CubeIntercept Saliva KitsInstant POCT Urine Test KitsAlcohol Test FormsQED Alcohol Test KitAlco Screen Alcohol Test KitQuantisal Swab Kits

Overnight? Yes No

Overnight Courier Name and Account Number

Comments

Comments