SETUP ONLINE ACCOUNT

Customer Account Profile

Note: Fields marked with * are required.
*Company Name:
*Phone:
Fax:		Secured Fax Line?
Address:
City/State/Zip:

Billing Address

Out of state collections

Estimated volume of samples a month:
*Testing Requested:		Include shipping
*Method of Receiving Initial Results:	If Fax number is not a secure line, please call before faxing results

Names of Persons authorized to receive results

1:		2:
3:		4:

*You must type I AGREE in Signature field to submit this form

Date: 03.09.2010