Collector Network Application

1 Business & Contact Information

Business name *

Contact name *

Phone *

Email *

Website (optional)

Business address

2 Collector Type & Service Area

Are you a mobile collector or a fixed collection site? *

Mobile collector Fixed collection site Both

Service area — cities / counties served *

States served *

3 Services Offered

Select all services you are qualified to provide.

4 Qualifications & Lab Accounts

Answering “No” to any lab affiliation does not negatively affect your application. We ask only so we know whether lab accounts or testing forms may need to be provided or set up for you if required. Lab affiliations are not a requirement to join the network.

Currently DOT collector qualified?

Currently BAT qualified?

Do you have your own lab accounts?

Do you work with Quest?

Do you work with Labcorp?

Do you work with CRL?

Do you work with Abbott / Alere Toxicology?

Do you work with Omega Laboratories?

Do you work with Psychemedics?

Do you have a physical collection site?

Do you offer observed collections?

Do you offer emergency / post-accident testing?

5 Additional Information

Notes / message (optional)