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Submitted URL: https://email.email.pandadoc.net/c/eJxNT8tuwjAQ_Bp8I_Irr0MOUAocqER7oKGXam1vICUPyzGF5utrDgiklXY0o92ZufTuNFjQ-F2bQms97PaL7d8Qm_GLXz...
Effective URL: https://app.pandadoc.com/document/8b7a1722e2db640f369a41db17abbb47c167ec9a
Submission: On September 15 via manual from US — Scanned from DE

Form analysis 1 forms found in the DOM

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Text Content

 1. APP_SADDLEBACK MEMORIAL MEDICAL CENTER_041921
    
    All changes have been saved



Business Credit and Account Application

header


COMPANY INFORMATION

heading


Company Name

Saddleback Memorial Medical Center

Business Address (No P.O. Boxes)


24451 Health Center Dr

City

Laguna Hills

State

California

Zip

92653

Phone

(949) 452-3950

E-Mail

dgrace@memorialcare.org

Fax

n/a


table


Check here if the information listed above is correct:


text
Diana Grace 







If the information above is incorrect, stop here and please contact your sales
rep so a new application can be sent with the correct information. Any edits to
the document will erase all fields you have previously filled.


text

pagebreak


PRIMARY CONTACT

heading


First Name

Diana

Last Name

Grace

Title

Manager of Medical Staff Office


Phone

(949) 452-3950

E-Mail

dgrace@memorialcare.org


Fax

n/a


table


Would you like to be a reporting contact? (all reports will be sent via Web
Portal)


 

May we use this contact for any specimen issue notifications?


 

May we use the email address above to send marketing communications such as:
Quarterly newsletters, announcements, etc?

 


table

  YesNo
Diana Grace 






  YesNo
Diana Grace 






  YesNo
Diana Grace 









If your organization doesn’t designate a contact to receive specimen issue
notifications, USDTL will assign the signatory as the default individual
receiving the report. 



text




For clients that use a shared general email box and would like to receive their
reports through our web portal: USDTL, Inc. cautions against the practice of
sharing login credentials such as user names, passwords, symbols or other
characters, as this can lead to identity theft, data breach, theft, or
corruption. User names and passwords should not be shared within any
organization. They are your individual logins, and should be treated as any
other confidential information you might collect and record.






text

pagebreak


ADDITIONAL CONTACTS

heading


If you have additional contacts, internal or external, who will be added to the
account, please complete the following and make sure to indicate whether or not
they are a reporting contact, specimen contact, and/or they would like to
receive marketing materials. If not, you may skip this section.


text


Name

Title

Email

Phone























table
Diana Grace 





Diana Grace 





Diana Grace 





Diana Grace 










Reporting Contact

Specimen Contact

Marketing Materials




 

 


table
Diana Grace 





Diana Grace 





Diana Grace 









Name

Title

Email

Phone























table
Diana Grace 





Diana Grace 





Diana Grace 





Diana Grace 










Reporting Contact

Specimen Contact

Marketing Materials




 

 


table
Diana Grace 





Diana Grace 





Diana Grace 









Name

Title

Email

Phone























table
Diana Grace 





Diana Grace 





Diana Grace 





Diana Grace 










Reporting Contact

Specimen Contact

Marketing Materials




 

 


table
Diana Grace 





Diana Grace 





Diana Grace 








pagebreak


ACCOUNTING CONTACT

heading


All invoices will be sent via:

Email

Are the Primary contact and the billing contact the same? If you select yes,
please skip to the "Credit Card" section.

 


table

  YesNo
Diana Grace 







Name

 

Title

 

Company

 

Department

 

Phone

 

E-Mail

 

Fax

 

Only fill out the address section if it is different from the business address
above.

Address

 

City

 

State

 

Zip

 


table
Diana Grace 





Diana Grace 





Diana Grace 





Diana Grace 





Diana Grace 





Diana Grace 





Diana Grace 





Diana Grace 





Diana Grace 





Diana Grace 





Diana Grace 
















pagebreak


APPLICATION SIGNATURE

heading


Signature of Applicant
















Printed Name

 


table
Click to sign
Diana Grace 






 * September 2021 SunMonTueWedThuFriSat 29 30 31 01 02 03 04 05 06 07 08 09 10
   11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 01 02 03 04 05 06
   07 08 09

   
 * Today Clear Done
   

Diana Grace 





Diana Grace 









United States Drug Testing Laboratories, Inc. (USDTL) is an Illinois Corporation
with its principal offices located at: 1700 S. Mount Prospect Road, Des Plaines,
IL 60018.  You can visit our website at www.usdtl.com



text


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