COVID-19 Rapid Test Kit Order Form

Name of Company*

Contact First Name*

Contact Last Name*

Contact Phone #*

Contact Email*

Shipping Street Address Line 1*

- Kits will be shipped overnight, but we cannot guarantee delivery date. - Kits cannot be shipped to a PO BOX.

Shipping Street Address Line 2*

Shipping City*

Shipping State*

Shipping Zip*

# of Kits*

Each Box Contains 25 Rapid Tests 1-4 Boxes = $950 per box 5-8 Boxes = $925 per box 9-12 Boxes = $900 per box 13 or more boxes call for special pricing

Select or enter value

Form of Payment*

Select or enter value

Bank Name

Routing #

Account #

Name of Card

Credit Card #

Expiration Date - MO/YY

CVV #

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