Supply Request
Please use this form to order supplies.
You will receive a confirmation within 1 hour, by either e-mail or voice, of your order.
Required fields are in red
Order date
Ordered by
Company
Street address
City
Province
Postal code
Email address
Phone number
Fax number
Chargeable Supplies
Collection Kits
6-Panel AutoSplit Cup
[box of 25]
Maxxam
[box of 25]
10-Panel AutoSplit Cup
[box of 25]
Maxxam - Saliva
[box of 25]
Oratect III Oral Fluid Kit
[box of 25]
Gamma Dynacare - DOT
[box of 25]
QED A150 (Saliva Alcohol)
[box of 10]
Gamma Dynacare - Non DOT
[box of 25]
ChemStrip 10
[tube of 100]
Breath Alcohol Supplies
Shipping Supplies
Alert J4X Mouthpieces
[pkg of 25]
Purolator to Maxxam
[each]
Drager 7410 Mouthpiece
[pkg of 25]
Purolator to Gamma Dynacare
[each]
DOT Breath Alcohol Form
[each]
Non-DOT Breath Alcohol Form
[each]
Chain of Custody Forms
MRO
Qty
DOT
Non-DOT
Maxxam
Gamma
Dynacare
Please call
888-378-4832
for additional
requests
Additional notes
