SAMPLE SUBMITTAL FORM
ACCUGEN LABORATORIES, INC
50 West, 75th Street Suite 209, Willow Brook, IL 60527
Tel: 630-789-8105 • Toll Free: 800-282-7102 • Fax: 630-789-8104
http://www.accugenlabs.com • Email: info@accugenlabs.com
SPONSER:________________________________________________________________
DATE:___________________________________________________________________
Address:________________________________________________________________
________________________________________________________________________
CONTACT:________________________________________________________________
EMAIL:__________________________________________________________________
PHONE:_____________________________________
FAX:_______________________________________
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| # |
TEST ORDERED |
SAMPLE ID |
LOT # |
| 1 |
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| 2 |
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| 3 |
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| 4 |
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| 5 |
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SAMPLE STORAGE INSTRUCTIONS
( ) Store at Room Temperature upon arrival
( ) Refrigerate upon arrival
( ) Freeze upon arrival
All Samples will be discarded after testing Unless Otherwise Indicated below:
( ) Discard Samples
( ) Retain Samples
( ) Return
TESTING INSTRUCTIONS
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Payment
Method |
Purchase
Order # |
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Accugen
Quote #
If Applicable |
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| Check |
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| Credit Card |
Visa MC AmEx |
| Card # |
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| ADDRESS: Do not enter if same as above |
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Authorization Sgnature:_____________________________________________________________
Date:___________________________________________________________________________
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