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Customer Profile Name

The company name as it will appear in the AVERWORX system

Location Name

How the location name should appear when ordering and on CCF forms

Location Address 1

Location Address 2

City

State

Zip Code

Primary Contact First Name

Primary Contact Last Name

Phone Number

Email Address

This will be the primary email for receiving test results and notifications

Fax Number (optional)

How many additional DERs do you need?

Designated Employer Representatives receive test results and can take action on positive results

Ship Cups #3

Account Type

Specimen Type

Lab Preference

POCT Cups – How many BOXES do you need?

Each box contains 25 cups. $10 per cup ($250 per box).

CCF Forms Quantity

Chain of Custody Forms for POCT and Non-DOT testing

Supplies Notes (optional)

Any special instructions for POCT supplies

Collection Site Pre-Print Information

If you have a preferred collection site, enter the details below. Leave blank to use our network of collection sites.

Collection Site Name

Collection Site Address

Collection Site City

Collection Site State

Collection Site Zip

Collection Site Phone

Collection Site Fax

Shipping Information

Where should we ship supplies?

Ship To Name / Attention

Ship To Address

Ship To City

Ship To State

Ship To Zip

Ship To Phone

Collection Site Pre-Print Information

Shipping Information

AVERWORX

Services

Contact

Email Address

Call Anytime