ACCUGEN LABORATORIES, INC.

SAMPLE SUBMITTAL FORM

LAB IDSAMPLE IDENTIFICATION / LOT NO.SAMPLE TYPESAMPLE DATEANALYSIS REQUESTED
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Client invoiced to:
Company:
Contact: Signature:
Address:
Phone:Fax:
Purchase Order Number:E.mail:
CHAIN OF CUSTODY:
Sampled by:Date:
Recieved by:Date:

Shipping Address

Accugen Laboratories, Inc.
50 West 75th Street, Suite 209
Willowbrook, IL 60527

Thank you for your business.

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Phone: 630-789-8105 Toll-free: 800-282-7102, Fax : 630-789-8104
Web: www.accugenlabs.com , E-mail : info@accugenlabs.com

site updated 03/27/07