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Get COLLECTION SITE INFORMATION (Please Complete Every Section Of This Form, If Something Does Not

Fax: ( ) Fax: ( ) Email address: Billing Name (Name of company that handles your invoicing): Billing Address: (City, State & Zip) Billing Contact: Ph: ( ) Employer ID Number (E.I.N.): 1099 - Yes **Please Fax W9 with Form or No (Information should be obtained from Accountant or Billing Dept.) **Fees (FirstLab is not responsible for payment of specimens rejected by the laboratory; sent to wrong lab; or collected on wrong CCF due to collector error) Collection ONLY DOT Urine Drug Scr.

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