Internal Order Form Scheduling System* MRO Alere DSI Third Party Background Check MVR DNA Other BGC Level* Entry Standard Executive Collection Fee* Collection Fee Paid at time of collection Collection Fee Invoice State Fees AK $10.00* AL $9.75 AR $13.00 AZ (3) $6.00 / (5) $8.00 CA $2.00 CO $2.20 CT $18.00 DC $13.00 DE $15.00 FL (3) $8.10 / (7) $10.10 GA (3) $6.00 / (7) $8.00 HI $23.00 IA $8.50 ID $9.00 IL $12.00 IN $7.50 KS $8.70 KY $5.50 LA $6.00 MA $8.00 MD $12.00 ME $7.00 MI $8.00 MN $5.00 MO $5.80 MS $14.00 MT $7.25 NC $8.00 ND $3.00 NE $3.00 NH $12.00* NJ $12.00 NM $6.50 NV $7.00 NY $7.00 OH $5.00 OK $27.50 OR $9.63* PA $8.00* RI $20.00 SC $7.25 SD $5.00 TN $7.00 TX (3) $6.50 / (5CDL) $7.50 UT $9.00 VA $7.00 VT $16.00* WA $13.00 WI $7.00 WV $9.00 WY $5.00 CN See Sherri PR $33.50 LAB* Specimen ID/Case Number* Tracking DOT / Non DOT Non - DOT FAA FMCSA FRA FTA PHMSA USCG Test Purpose Pre Employment Random Post Accident Reasonable Suspicion Other 5 Panels 5 Panel Instant 5 Panel 5 Panel DOT LIKE -N 5 Panel + ETG 5 Panel + Alcohol 5 Panel DOT 5 Panel + Exp Opiates 5 Panel + Nicotine 5 Panel + Exp Opiates + Alcohol 5 Panel Florida Drug Free 10 Panels 10 Panel 10 Panel Instant 10 Panel DOT LIKE - N 10 Panel + Alcohol 10 Panel + Exp Opiates 10 Panel + BUP 10 Panel Florida Drug Free 10 Panel + Exp Opiates + MDMA 10 Panel + Exp Opiates + BUP 10 Panel + ETG 10 Panel DOT Like + MEP + TRAM 10 Panel + Exp Opiates + MEP + FEN 10 Panel + Exp Opiates + MDMA + ETG 10 Panel DOT Like + Exp OPI + OXY + MEP + TRAM + FENT Hair Tests 5 Panel 5 Panel + Exp Opiates + OXY 9 Panel 12 Panel 14 Panel 17 Panel ETG Hair Body Hair Collection Blood & Misc. Occupational Health Service Blood Alcohol 5 Panel + Alcohol 5 Panel + Exp Opiates + OXY 7 Panel Alcohol Alone Physicals ETG Breath Alcohol DOT Compliance Package Drug Policy Background Check MVR Consortium Enrollment/Renewal Observed Collection Occupational Health Services* Background* Entry Standard Executive Date of Birth* Date Format: MM slash DD slash YYYY Shipping/Overnight Amount / Total Payment* Invoice Paid Online Order Pre Paid Total Test Pre-Paid* 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 Number of Pre Paid Tests Remaining* 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 Pre-paid notes* Company Name* Payment Information* Credit card number Exp date Cardholder Name CVV Billing zip code Donor Info Name SS# Phone Zip Donor Email / Results Email Donor Pass Email Results Email Notes Post Custom Field Drop files here or Accepted file types: pdf. This iframe contains the logic required to handle Ajax powered Gravity Forms.
