New Client Information

Company Name

Physical Address

Phone

City

State

Zip

Health Insurance will be billed if provided by employees at the time of service. Billing information will only be used in the event there are additional fees agreed to by the employer such as on-site testing fees or employees do not provide insurance at the time of service. Check if billing address is the same as above Health Insurance will be billed if provided by employees at the time of service. Billing information will only be used in the event there are additional fees agreed to by the employer such as on-site testing fees or employees do not provide insurance at the time of service. Check if billing address is the same as above same as above

Indicate billing delivery method Indicate billing delivery method Fax Mail E-Mail

Billing Contact E-Mail

Billing Fax

Billing Contact Name (Name on invoice)

Billing Contact Phone

Billing City

Billing Address

Billing State

Billing Zip

Please indicate any special instructions:

COVID testing is conducted at the following locations: COVID testing is conducted at the following locations: TED STEVENS ANCHORAGE INTERNATIONAL AIRPORT - 5000 W International Airport Rd, Anchorage, AK 99502 -- Hours: 24/7 CAPSTONE FAIRBANKS - 3121 Airport Way, Fairbanks, AK 99709 -- Mon-Fri: 8:00 am - 5:00 pm, Sat-Sun: 9:00 am - 5:00 pm CAPSTONE SEARS - 1000 S Seward Meridian Pkwy, Wasilla, AK 99654 -- Mon-Fri: 8:00 am - 6:00 pm Sat-Sun: 10:00 am - 3:00 pm CALISTA COURT - 301 Calista Court, Ste 102, Anchorage, AK 99518 -- Mon-Fri: 8:00 am - 6:00 pm, Sat-Sun: 9:00 am - 5:00 pm CAPSTONE KENAI - 15043 Kenai Spur Hwy, Kenai, AK 99611 -- Mon-Fri: 9:00 am - 5:00 pm, Sat: by appointment only CAPSTONE NORTH POLE - 301 Santa Claus Ln, Lot #7, North Pole, AK 99705 -- Mon and Fri: 9:00 am - 4:00 pm, Wed: 12:00 pm - 7:00 pm FAIRBANKS INTERNATIONAL AIRPORT - 6450 Airport Way, Fairbanks, AK 99709 -- Mon-Sun: 6:30 am - 12:00 am JUNEAU INTERNATIONAL AIRPORT - 1873 Shell Simmons Dr, Juneau, AK 99801 -- Mon-Sun: 8:00 am - 11:30 pm KETCHIKAN INTERNATIONAL AIRPORT - 1000 Airport Terminal Building, Ketchikan, AK 99901 -- Mon-Sun: 7:30 am - 8:30 pm ALASKA AIRLINES CENTER - 3550 Providence Dr, Anchorage, AK 99508 -- Mon-Sun: 8:00 am - 4:00 pm CAPSTONE DILLINGHAM - 240 Harbor Road, Dillingham, AK 99576 -- Mon-Sun: 12:00 pm - 6:00 pm DEADHORSE AVIATION CENTER - 500 1st St, Prudhoe Bay, AK 99734 -- Mon-Sun: 6:00 am - 6:00 pm

DESIGNATED EMPLOYEE REPRESENTATIVES (DER) DESIGNATED EMPLOYEE REPRESENTATIVES (DER) A Primary DER is the employee (or employees) from your company that is (are) responsible for the administration of your company’s account with Capstone. Capstone requires at least one Primary DER and one Alternate DER. An Alternate DER Authorization Form must be completed for each Alternate DER. For multiple Alternate DER’s, please make copies of this form. Incomplete forms may result in processing delays.

Primary DER Name (Last, First, MI)

Primary DER Phone

DER Alternate Phone

Primary DER Fax

Primary DER Email

Secondary DER Name (Last, First, MI)

Secondary DER Phone

Secondary DER Alternate Phone

Secondary DER Fax

Secondary DER Email

Date

Authorized Representative Name