Combined Lab Application Form

Applicant Name *

First Name

Last Name

Applicant Phone *

(###)

###

####

Primary Business Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Shipping Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Office Phone *

(###)

###

####

Partner Lab I Wish to Sign Up For: *

(Select one or multiple)

EDO (Dallas)

RND (Ohio)

Pivotal Will Choose For Me

I acknowledge enrollment in Auto-Pay. *

Having a Pivotal Lab account requires enrollment in auto-pay via ACH withdrawal. Clients will be provided statements several days prior to automatic withdrawal to allow time to review and/or dispute any unrecognized or incorrect charges. By checking this box, you acknowledge and agree to being enrolled in auto-pay. Accounts may be managed and charged by Pivotal Group, or their partner company Optic Ascent LLC. By signing, you acknowledge Pivotal Group and/or Optic Ascent or possibly another third party will use this bank information to process payments for these lab services. You may request changes to the payment information on file at any time be contacting Pivotal Group at least 72 hours before payment due date. Any changes to payment info on file will incur a $1.00 application fee to verify that the information provided is valid. You acknowledge you will be responsible for any fees assessed against Pivotal Group if this information results in an unsuccessful ACH withdrawal.

I acknowledge Autopay.

Authorized Personnel *

By checking this box, you indicate that you have the authority and permission to register this business for a new PLN account. IP addressed are recorded with every submission for verification purposes.

I have the authority to create new accounts for this business.