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This section will provide us with a general understanding of the structure and individual needs of your business.
General Business Information
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This information will ensure our ability to effectively communicate with you in regardes to our services, and as such, it is critical that it be both fully complete and accurately maintained. Individuals MAY NOT be listed as serving more than a single role.
Corporate Contact Info - Corporate Officer
Copy from Main Mailing Address
Corporate Contact Info - Primary DER
This information will ensure our ability to effectively communicate with you in regardes to our services, and as such, it is critical that it be both fully complete and accurately maintained. Individuals MAY NOT be listed as serving more than a single role.
Copy from Main Mailing Address
Corporate Contact Info - Secondary DER
This information will ensure our ability to effectively communicate with you in regardes to our services, and as such, it is critical that it be both fully complete and accurately maintained. Individuals MAY NOT be listed as serving more than a single role.
Copy from Main Mailing Address
Primary Contact - Billing and Payables
This information will ensure our ability to effectively communicate with you in regards to the billing and payment of those services which we provide, or remit to others on your behalf.
Copy from Main Mailing Address
Primary Contact - Random Program Management
This information will aide us in identifying the person primarily responsible for the effective oversight of your random testing program, including the updating of participant lists, completion of testing, requesting of alternate selections, annual reporting, etc.
Copy from Main Mailing Address
Employee Demographics
Collection Site & Other Vendors

Please indicate those services which you currently receive from an outside vendor, and the name of the supplier for each

Examples:
Laboratory: CRL
Medical Review Officer: Dr. Jane Dow
Instant Test Devices: XYZ DrugDetect
Current Testing Program
Service Agreement Checklist & Restatement of Important Policies
The following checklist is designed to afford you with an easy means of ensuring that you supply us with all information necessary for the execution of the Service Agreement. Failure to provide or produce this information may dleay or prohibit the execution of our agreemement, and our ability to begin or continue to provide service to you.
Confirm and Submit

I, , acting as a duly authorized representative of , attest that the information contained herein is both true and accurate. I understand that it is my responsibility to immediately update this information as it changes, or otherwise, as it is required.

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