"*" indicates required fields Step 1 of 4 25% CommentsThis field is for validation purposes and should be left unchanged.ContactSupervisorWho is Completing This FormSupervisor*Name*Telephone*Telephone*Email* Type of FacilityRequest DatesUntitled* IOP (Priority) PSC Today* MM slash DD slash YYYY Preferred Transport Method* Standard Transport EMERGENCY OR EXPEDITED TRANSPORT (Less than 3 Days' Notification) FACILITY RELOCATION (After completing form, call (678) 887-8363 for all Facility Relocations.) Date Needed* MM slash DD slash YYYY Choose One*Pick Up & DeliveryPick Up OnlyDelivery OnlyAlternate Date* MM slash DD slash YYYY Pick Up InformationSite ContactSite Info On-Site Contact Person on Pick up Day*Site Name*Is site closed during lunch?* Yes No If Yes, Include lunch hoursTelephone*Address* Street Address Suite Number City State*AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Is this your address* Yes No Alt. TelephoneDays & Hours of Operations*Site Code*Items to pick upTask Chair w/ArmsQuantity12345678910Tall Task ChairQuantity12345678910Phlebotomy ChairQuantity12345678910Phlebotomy CartQuantity12345678910Refrigerator (3.1 cu. ft.)Quantity123456789102 Drawer File CabinetQuantity12345678910Copier and TonerQuantity12345678910Phlebotomy ReclinerQuantity12345678910Other info Delivery InformationSite ContactSite Info If Yes, Include lunch hoursOn-Site Contact Person on Delivery Day*Site Name*Is site closed during lunch?* Yes No Telephone*Address* Street Address Suite Number City State*AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Is this your address* Yes No Alt. Telephone*Days & Hours of Operations*Site Lunch Hours*Site Code*Items to deliverTask Chair w/Arms*Quantity12345678910Tall Task Chair*Quantity12345678910Phlebotomy Chair*Quantity12345678910Phlebotomy Cart*Quantity12345678910Refrigerator (3.1 cu. ft.)*Quantity123456789102 Drawer File Cabinet*Not AvailableCopier and Toner*Quantity12345678910Phlebotomy Recliner*Quantity12345678910Other info AuthorizationConfirmationName*Telephone*Untitled* Confirmation Addresses are GPS-worthy. Untitled* Confirmed this order has been authorized by a Quest Diagnostic Laboratories, Inc. Supervisor. Untitled* I have read and understand items 1- 6. 1.We require 3-5 business days prior notice on all Standard Transport & Delivery Requests. 2.Requests made with less than 72 hours prior notification constitute an Expedited or Emergency Move, and will incur additional costs. 3.Expect a 3-5 hour window on all deliveries and pickups. 4.Confirmation of receipt of request will be e-mailed to the email address provided in the form for supervisor. 5.Availability of items (if applicable) will be sent by telephone or e-mailed to the supervisor or lead. 6.Orders received after 5:00 PM will be processed the next business day. 7.Submitter of form confirms that the on-site contact person will be available during delivery days and times. Δ "*" indicates required fields Step 1 of 4 25% X/TwitterThis field is for validation purposes and should be left unchanged.ContactSupervisorSupervisor*Telephone*Email* Who is Completing This FormName*Telephone*Type of FacilityUntitled* IOP (Priority) PSC Preferred Transport Method* Standard Transport EMERGENCY OR EXPEDITED TRANSPORT (Less than 3 Days' Notification) FACILITY RELOCATION (After completing form, call (678) 887-8363 for all Facility Relocations.) Request DatesToday* MM slash DD slash YYYY Date Needed* MM slash DD slash YYYY Choose One*Pick Up & DeliveryPick Up OnlyDelivery OnlyAlternate Date* MM slash DD slash YYYY Pick Up InformationSite InfoSite Name*Is this your address* Yes No Site ContactOn-Site Contact Person on Pick up Day*If Yes, Include lunch hoursIs site closed during lunch?* Yes No Telephone*Address* Street Address Suite Number City State*AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Alt. TelephoneDays & Hours of Operations*Site Code*Items to pick upTask Chair w/ArmsQuantity12345678910Tall Task ChairQuantity12345678910Phlebotomy ChairQuantity12345678910Phlebotomy CartQuantity12345678910Refrigerator (3.1 cu. ft.)Quantity123456789102 Drawer File CabinetNot AvailableCopier and TonerQuantity12345678910Phlebotomy ReclinerQuantity12345678910Other info Delivery InformationSite InfoSite Name*Is this your address* Yes No Site ContactIf Yes, Include lunch hoursOn-Site Contact Person on Delivery Day*Is site closed during lunch?* Yes No Telephone*Address* Street Address Suite Number City State*AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Alt. Telephone*Days & Hours of Operations*Site Lunch Hours*Site Code*Items to deliverTask Chair w/Arms*Quantity12345678910Tall Task Chair*Quantity12345678910Phlebotomy Chair*Quantity12345678910Phlebotomy Cart*Quantity12345678910Refrigerator (3.1 cu. ft.)*Quantity123456789102 Drawer File Cabinet*Not AvailableCopier and Toner*Quantity12345678910Phlebotomy Recliner*Quantity12345678910Other info AuthorizationConfirmationName*Telephone*Untitled* Confirmation Addresses are GPS-worthy. Untitled* Confirmed this order has been authorized by a Quest Diagnostic Laboratories, Inc. Supervisor. Untitled* I have read and understand items 1- 6. 1.We require 3-5 business days prior notice on all Standard Transport & Delivery Requests. 2.Requests made with less than 72 hours prior notification constitute an Expedited or Emergency Move, and will incur additional costs. 3.Expect a 3-5 hour window on all deliveries and pickups. 4.Confirmation of receipt of request will be e-mailed to the email address provided in the form for supervisor. 5.Availability of items (if applicable) will be sent by telephone or e-mailed to the supervisor or lead. 6.Orders received after 5:00 PM will be processed the next business day. 7.Submitter of form confirms that the on-site contact person will be available during delivery days and times. Δ
