Pivotal Partner Lab Application

Business Legal Name*

Business DBA Name*

Re-enter legal name from above if no DBA.

Main Contact for Lab-Related Questions*

First Last

Main Billing Contact Name*

First Last

Office Address*

Street Address Address Line 2 City State ZIP Code

EXACT Shipping Address*

Same as office address

Street Address Address Line 2 City State ZIP Code

Include any suite numbers, building numbers, floor numbers, etc. Any fees charged by UPS due to an incorrect or imprecise shipping address will be client's responsibility.

Employee-Accessible Email Address*

This address will be used for status reports, important lab notifications, etc.

Type of Lab Account*

Uncut Jobs Only

Uncut Jobs + Complete Jobs

Preferred Lab*

EDO (Dallas)

R&D (Ohio)

No preference

Preferred Billing Email Address*

This is where all paperless billing correspondence such as PLN statements, invoices, etc. will be sent.

Phone Number for Billing Inquiries*

Leave blank if same as office phone.

Bank Name

Bank Account Number*

Bank Routing Number*

Bank Account Type*

Checking

Savings

Electronic Signature*

Must be signed by an owner or authorized user of the bank account submitted for ACH autopay on this application.

Pivotal Partner Lab Application.

Pivotal Partner Lab Application Form