test contact

Accounts Payable Contact

Name:

Phone:

Email:

Billing Address

Full name

Name of Company

Address line 1

Address line 2

City

State

Zip Code

Phone number

Email Invoice to:

Shipping Address

Same as Billing Address
Enter your information

Scheduling Contact

Enter your information
Same as Billing Address

PAYMENT INFO (Disregard CC info if not applicable)

Method:
Credit CardYes, Keep my credit card on file for future service.
PO Required:
YesNo

Name on Card:

Card Number

Security Code

Expiration

CC Billing Address

Additional Notes:

(internal use only) Customer #:

Tax Exempt:
YesNo

Tax ID number

Phone:

Drug Test:
UrineAlcoholDISAHairBloodNASAPNone

Safety/Site Specifics

HASCISTCPO Required before ServiceOtherNone

PPE Required:
FRC LabcoatFRC CoverallsSafety GlassesHard HatSteel-toed shoesOtherNone

Please provide the recertification interval of your service. This determines "Next Due Date" on your reports.

Recertifcation Interval months Next Due Date Format:

Quality Metrics:
SO 17025 * ‡SO 9001 ‡U.S. PharmacopeiaNSF 49I don’t knowOther

* Would you like us to account for measurement uncertainty when determining pass/fail?
YesNo

If so, Allometrics will provide three determinations: Pass, Fail, or Unknown - unless otherwise specified.

‡ Would you like Allometrics to determine pass or fail based upon specifications?
YesNo
Contact me later
YesNo

Please provide the source of the specifications you would like us to use during our service:

SHIPPING INFORMATION (If not specified, Allometrics will ship using UPS Ground, prepay, and add)

Customer Shipping Account#:

Ship via:
UPSFedExUSPSDrop off/PickupOther

Shipping method:

GroundPriority2nd DayOvernight