Supply Re-Order Form Phone: 215-443-0531 Fax: 215-675-5353 Date of Order: 7/31/2010 Name of Person Ordering Supplies: **First and Last Name of Person to Receive Supplies Must be Included** Phone Number of Person Ordering Supplies:(xxx-xxx-xxxx):   I am Ordering supplies for the company listed below that uses DRUGSCAN for drug testing: Name of Company: Acct.No AND Location Code: The account number can be found under the small bar code in Step 1, between A(Employer Information) and B(MRO Name, Address, Phone and Fax No.) on Chain of Custody form. **If you do not have a Chain of Custody form and do not know the account number, call 215-674-9310 for assistance** Orders cannot be filled without the account number and location code. "Ship To" Information Facility/Company Name: Attn: Shipping Address: City: State/Province: |Zip/Postal Code: Country/Region: USA Canada Phone Number:(xxx-xxx-xxxx):   Shipping Instructions: Product ID Quantity Supplies: For Office Use Only 1 Black Split Sample Kits 25204 2 DOT(Federal) Chain of Custody (Black & White) 7P201 3 Non-DOT Chain of Custody (Blue & White) 5P201N 4 FedEx Billable Stamps 5 Lab Paks 6 RED Kits         Allow Up to 10(Ten) Working days for receipt of an Order. **If Overnight or 2nd day shipping is required, only client may order.** Please Double Check your order before submitting.