53673

e-LAB Solutions ConnectTM

Order Form

Name of Laboratory:

DI Number:

CAP Program Code: 3572LM

Ordering Contact Information (required)

Name:

Email Address:

Address:

City:

State: ZIP:

Phone:

Billing Information (if different)

Name:

Email Address:

Address:

City:

State: ZIP:

Phone:

Payment Method (required)

Card Number:

Exp. Date:

Card Holder's Name:

Signature:

Check, made payable to College of American Pathologists

P.O.

Visa Master Card Amex

Number:

Price per CAP Number$895 for the full year inclusive of all CAP licensing, maintenance, and automated reporting fees.

Submit electronic form below or mail or fax printed form to:

Phone: 800-323-4040 or 847-832-7000 option 1 Fax: 847-832-8168

College of American Pathologists CDM (e-LAB Solutions Connect) 325 Waukegan Road Northfield, IL 60093

CAP Number Name (authorized user) Email Address Phone Number

$895

$895

$895

$895

$895

$895

$895

$895

$895

$895

$895

$895

Price

Total:

e-LAB Solutions Connect Contact