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Company Name

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Email

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Billing Name & Address

Cardholder Name

Billing Address

Billing Address Line 2

City

State/Province

Postal Code

Credit or debit card

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Number of Tests per Billing Period	Price Per Test
1	$89
2 - 5	$50
6 - 10	$25
11 - 15	$60
16 - 20	$50
21 - 30	$45
31 - 50	$40

For volumes greater than 50 per month, please call.