Sample Analysis Request Form Submitted by
Report to
Bill to
Contact, Company, Address, Phone, Fax, Email
Contact, Company, Address
Contact, Company, Address, Phone
Client Code: Eurofins Quote #:
Email To: CC on email:
Email To: PO #
Eurofins ID
Organism, Method Reference
Eurofins use only
Requested Analyses and Method
Requested Weight (Pathogens)
e.g., corn, soy, cookie, pet food, food supplement This will appear on the Report of Analysis
e.g., Barge #, Lot #, Production Date, Lab # This description will appear on the Report of Analysis
Estimated Value (Quantitative)
Sample Reference
Sample Description
Special Instructions:
CHAIN OF CUSTODY INFORMATION Method of Sample Shipment
Sample Relinquished By
Time
Date
Sample Received By
Eurofins Microbiology Laboratories, Inc. 2430 New Holland Pike, Suite D-215 Terms and Conditions are available on www.EurofinsUS.com /Terms_and_Conditions.pdf Lancaster, PA 17601 www.eurofinsus.com
Time
Date
Telephone +1 717-556-7373 Fax +1 717-556-3743
[email protected]
