Internal Order Form Internal Order Form Scheduling System*MROeScreenAlereThird PartyBackground CheckMVRDNAOtherCollection Fee*Collection Fee Paid at time of collectionCollection Fee InvoiceCase Number*State FeesAK $10.00*AL $9.75AR $13.00AZ (3) $6.00 / (5) $8.00CA $2.00CO $2.20CT $18.00DC $13.00DE $15.00FL (3) $8.10 / (7) $10.10GA (3) $6.00 / (7) $8.00HI $23.00IA $8.50ID $9.00IL $12.00IN $7.50KS $8.70KY $5.50LA $6.00MA $8.00MD $12.00ME $7.00MI $8.00MN $5.00MO $5.80MS $14.00MT $7.25NC $8.00ND $3.00NE $3.00NH $12.00*NJ $12.00NM $6.50NV $7.00NY $7.00OH $5.00OK $27.50OR $9.63*PA $8.00*RI $20.00SC $7.25SD $5.00TN $7.00TX (3) $6.50 / (5CDL) $7.50UT $9.00VA $7.00VT $16.00*WA $13.00WI $7.00WV $9.00WY $5.00CN See SherriPR $33.50LAB*Specimen ID/Case Number*TrackingDOT / 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 Body Hair Collection Blood & Misc. 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 Amount / TotalPayment*InvoicePaidOnline OrderPre PaidTotal Test Pre-Paid*1234567891011121314151617181920Number of Pre Paid Tests Remaining*01234567891011121314151617181920Pre-paid notes*Company Name*Payment Information*Credit card numberExp dateCardholder NameBilling zip code Donor InfoNameSS#PhoneZip Donor Email / Results EmailDonor Pass EmailResults Email NotesFile Upload Drop files here or
