iCup At Home Drug Screen Kit 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):                 
 
 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:
CheckVisaMastercard
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