C/TPA - Corporate Quote Request

Type Industry:
Company Name:*

Contact: Contact Title:
Cell phone:


Type of Program:
Scope of Program:  
  Number States:
  Number Locations:
  Number Providers:
  Number Employees:

Test Pool Size Per Type:
  Non-Regulated or State-Regulated Program:
  DOT Look-alike:
  Drug Panels Tested:

  Rregulated Program:
  DOT Agency Annual Random Testing Rate Random Test Pool
   Drug Alcohol  
  FAA 25% 10%
  FMCSA 50% 10%
  FRA 25% 10%
  FTA 50% 10%
  PHMSA 25% N/A
  USCG 50% N/A

Volume of All Categories of Drug Testing(estimated):
  Regulated: Per Year:   Per Month:
  Non-Regulated: Per Year:   Per Month:

On-Site Collections:

Supervisor Training:
Program Policy :
Laboratory Preference :
Other Needs:

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