Drug Free Business after-hours "Shy Bladder" billing protocolNameThis field is for validation purposes and should be left unchanged.Shy Bladders/Quantity Not Sufficient Protocol (QNS). DOT Rule 49 CRF Part 40 Section 40.65 In the event of a shy bladder, the DOT drug testing protocol requires the donor to stay and try to provide a sufficient specimen within a 3-hour time frame. If this wait time extends past the closing time for Drug Free Business's normal business hours, a flat fee of $150 will be billed for after-hours collections. This will cover a wait-time for our collectors of up to 3 hours after closing. (currently 3:30 p.m.) This will apply to NON-DOT as well as DOT collections performed at our Bothell, WA collection site.Company Name*Billing Address* Street Address Address Line 2 City 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 Billing Contact Name: First Last Billing PhoneBilling Contact Email If different from DER.Name of Designated Employer Representative (DER):*Person responsible for your drug testing programDER PhoneDER fax:Needed so we can fax back Employer's copy of custody & control formDER's Email By completing and submitting this form your company hereby acknowledges responsibility for payment in full.Name of person submitting this form* First Last