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:_______________________________________
# TEST ORDERED SAMPLE ID LOT #
1
2
3
4
5
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







Payment
Method
Purchase
Order #
Accugen
Quote #
If Applicable
Check
Credit Card Visa   MC   AmEx
Card #
ADDRESS: Do not enter if same as above
Authorization Sgnature:_____________________________________________________________

Date:___________________________________________________________________________
For Lab Use Only Sample Condition Date
Sample inspected and logged by:  
Sample Received By: