Supply Request Form

 "NOTE: If you have filled out the below form correctly an automatic email will be sent to the email address indicated stating that the order has been received."

Please use this form to order supplies.  We will contact you to let you know that the order has been received and when it will be shipped.

For immediate assistance, please call:

1-866-944-4473

email address: Leave this field email-address blank:
Homepage: Leave this field homepage blank:
URL: Leave this field url blank:
Comment: Leave this field comment blank:

Required Information
Ordered By*:
Company*:
Purchase Order # (if applicable):
Mailing Address*:
City*:
Province/Territory*:	AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland & LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon
Postal Code*:
Phone Number*:
Email *:
Fax Number:
Method of Delivery*:	Pick up at SureHire Mail
Supplies (Please indicate how many you would like numerically)
5 Panel Multi-Drug Screen:
12 Panel Multi-Drug Screen:
Oral Fluid Drug Test - Express Kit:
Oral Fluid Drug Test - Lab Based Kit (includes CoC forms):
QED:
Maxxam Analytics Non-DOT Kits (includes CoC forms):
Maxxam Analytics DOT Kits (includes CoC forms):
Omega Hair Kits (includes CoC forms):
Additional Notes/Comments
Notes/Comments:
Verification Code
Verification:	Fill in the text