Name		Street Address
Location Code (if applicable)		Street Address must be a physical street address. NO P.O. BOXES
Organization		Address (cont.)
Work Phone		City
FAX		State/Province
E-mail		Zip/Postal Code

KIT ORDER SECTION - Questions?	[ENTER  QUANTITY. EX. 6,24,50 or Other]
DOT DRUG KIT ?
NON-DOT DRUG KITS  ?
DOT BREATH ALCOHOL KITS ?
NON-DOT BREATH ALCOHOL KITS ?
DOT POST-ACCIDENT D/A KITS
NON-DOT POST-ACCIDENT  D/A KITS
CLIENT REQUIRED DRUG/ALCOHOL KITS ?
CLIENT REQUIRED ALCOHOL KITS ONLY ?
BROCHURES ORDER SECTION	[ENTER QUANTITY. EX. 6,24,50 or Other]
EMPLOYEE BROCHURES (English) (Available in PDF)
EMPLOYEE BROCHURES (Spanish) (Available in PDF)
SUPERVISOR'S BROCHURES
NATIONAL HOTLINE/HELP LINE POSTERS (English)
NATIONAL HOTLINE/HELP LINE POSTERS (Spanish)
DRUG AND ALCOHOL TRAINING DVD'S AND BOOKS  (Training DVD available online)
ADDITIONAL SHIPPING/ORDER COMMENTS:
NOTICE: UPS Ground service is provided at no cost. Shipping and Handling will be charged to your company for all other priority shipping services.   NOTICE: Orders may be processed the following day. PLEASE UTILIZE THIS ONLINE FORM WHEN ORDERING ADDITIONAL KITS.  ALSO BE SURE TO CHECK YOUR KIT SUPPLY OFTEN.  WHEN YOUR SUPPLY OF KITS IS LIMITED TO A MINIMUM OF SIX (6) EACH.  TO ENSURE THERE IS NO DELAY IN SHIPPING, PLEASE USE THIS FORM.  MAKE SURE EACH STEP IS FILLED OUT.  ALL ORDERS WILL BE SHIPPED VIA UPS (REGULAR GROUND).