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Cup At Home Drug Screen Kit Order Form
Order Form
SHIP TO:
Name
Company Name
Street Address
City,ST ZIP
Phone
BILLING ADDRESS:
Name
Company Name
Street Address
City,ST ZIP
Phone
Select ICup Quantity ($19.95/Each):
Select ICup Quantity
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
ITEM(S)
UNIT PRICE
SUBTOTAL
S&H
TOTAL
Shipping and Handling Charges:
Via Priority Mail-U.S. Postal Service:
*Federal Express Standard Overnight:
$5.95 for 1-3 kits
$30.00 for 1-5 kits
$7.00 for 3-10 kits
$38.00 for 6-10 kits
$10.00 for 11-24 kits
$65.00 per case (25 kits)
$16.00 per case (25 kits)
*Please Note: Rush Orders received after 2:00 p.m. EST will not be processed until the
following business day.
Comments/Special Instructions:
Payment Method:
Select Method:
Check
Visa
Mastercard
Credit Card Number:
Name on Card:
Expiration Date:
Email Cofirmation:
650 SW 34th Street, Suite 301, Ft. Lauderdale, FL 33315 - Phone: 954-635-2098 - Fax: 954-359-9448
Questions?
CALL US NOW:
Tel: (954) 635-2098
Fax: (954) 359-9448
Toll–Free: 1-888-378-4640
