Collection Affiliate Application Form Facility Name Contact Person Address City Select State ALAKAZARCACOCTDEDCFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWY Zip Fax Email Do you have an instant camera on hand? Yes No Do you have internet access? Yes No Do you have a phlebotomist licensed to collect blood samples? Yes NoHours of Operation In-Office Monday Tuesday Wednesday Thursday Friday Saturday Sunday Mobile Monday Tuesday Wednesday Thursday Friday Saturday SundayPatient Scheduling Scheduling Contact Phone Address patient is sent to (if different from address above) Address to ship your DNA kits (if different from address above) Your fee for DNA Office Collections ($) Your fee for DNA Mobile Collections ($) Billing Will send monthly invoice to Choice DNA with date of service, patients’ names, and case number. Yes I’d like to receive electronic payment via credit card, Zelle, or PayPal after each collection. YesAre you a vendor/reseller or paternity testing with any other labs? First Reference Name 1st Ref Phone 1st Ref Relationship Second Reference Name 2nd Ref Phone 2nd Ref Relationship May we contact these references? Yes No Do you provide specimen collection for other companies? Yes No Are you vendor/reseller of paternity testing? Yes No Please list the labs you currently outsource paternity testing to: By submitting this document you are giving Choice DNA Laboratory permission to put your name and or company name in our online database to search as an available collector. Yes Affiliate Number Submit
