Sponsor:  (Your company's name)

 

  
Contact:  (One person authorized to answer technical questions and receive the final report)

 

  
Street Address:  (Your company's address. This is where the final report will be sent. If applicable, please indicate billing address in the comments section)

 

  
City:  
State:  
Zip:  
Phone:  
Fax:  
Email:

 

  
   

Sample Information
Sample Description Test Description Number of Samples Lot/Code Number
 

 
Additional Sample or Test Information:

 

Please list any specific standard, test method, or regulatory requirements, not identified in the SAL test description, to which the testing must conform.  Also, include any additional information, special billing information, safety precautions, sample handling, etc.

 
 
 

 
Shipment Method:
Tracking Number:
Shipment Date:
Purchase Order Number:
Amount:
Date Preliminary Test Report is Required:  
Send Preliminary Test Report Via:   Fax     Email     Overnight Courier*

 
 

GLP Study  (Extra charge of $250 applies)
Perform Study Using GLP?    Yes     No
Return Samples?     Yes     No

 
 

Sample Storage Conditions

 Ambient   Refrigerate   Freeze              Other (specify)
Comments:

 
   
Sterilization Method:

(If applicable)

 Ethylene Oxide     Radiation     Steam       Other (specify) 

 
Samples Aerated/Degassed? Yes     No

 

* Additional packaging and freight charges will be billed, at cost, to the sponsor.