Private Saliva Testing Account Application FormClient Application Form Client DetailsFull Legal Business Name(Required)Business type(Required)Please tick one option Sole Trader Partnership Ltd CompanyPhysical address(Required)Post code(Required)Contact name(Required) First Last PositionEmail(Required) Contact number(Required)Local or National Presence Local presence only National presence OtherSector / Industry(Required)Ownership details Please provide the full name and contact details of Owners/Directors of the business.Name: Owner/Director 1(Required) First Last Phone and address: Owner/Director 1(Required)Name: Owner/Director 2 First Last Phone and address: Owner/Director 2Name: Owner/Director 3 First Last Phone and address: Owner/Director 3Trade references Trade reference cannot be a utility providerCompany name 1Contact name 1Phone no. 1Account no. 1Company name 2Contact name 2Phone no. 2Account no. 2Accounts payable detailsAccounts payable contact name(Required) First Last Email address for invoices(Required) Contact number(Required)Single or combined invoices(Required) Single CombinedAddress if different from aboveTesting requirementsSample collection(Required)How will we collect your saliva samples for testing? We have 85 drop off locations nationwide. Dropped off to local collection site Workplace pick up as arranged with APHG (only available for high volumes and prearranged)Expected volumes of tests per week(Required)Contact person for test results(Required) First Last Email address for test results(Required)Can be a generic email Phone no.(Required)For critical test result purposesI / We confirm the following:1.(Required) The above information is true and correct2.(Required) That the person signing this form has authority to enter into this application and future contracts on behalf of this business. I/we understand that APHG may conduct credit checks as part of this applicationName(Required)By typing your name you are electronically signing this application form. At least one name is required. First Last NameBy typing your name you are electronically signing this application form. First Last Δ
