Print Out Water Samples Form

Particle Size / Count Analysis Service Form

Please fill out the form below, and click on 'Submit' to print final format for shipping with samples:

Ship approximately 200 mL, or 6 oz per sample in well sealed plastic container(s). Spectrex recommends overnight shipment for samples that might foster bacterial growth - It is very important to label all bottles, containers and packages.

Referred by:
Date:
Submitted by (Full Name):
Title of Sample(s):
Number of Samples:

SEND RESULTS TO:
Company Name:		Attention:
Address:
City:		State:
Country:		Zip:
Phone:		Fax:
E-mail:
How do you want results sent? (please choose maximum of two methods)	by fax by e-mail

BILL TO:	Same as Above	Purchase Order #:	**
** NOTE: If your Accounts Payable Department requires a Purchase Order Number for payment it MUST be provided on this form. (Visa, American Express, MasterCard accepted)
Company/Cardholder's Name:		Attention:
Card Number:	Write on this form once printed. (for security purposes)	Expiration Date:	/
		Card Verification Number	Click here for help.
Address:
City:		State:
Country:		Zip:
Phone:		Fax:
Specific gravity of the solids?
Are these solids magnetic?		Yes No
I want to order discounted label/bottle kits. (Check price window for discounts)		Yes, please call me. How many?
Does the sample contain any hazardous material? If yes, explain (MSDS and special handling instructions must accompany all hazardous samples). (extra charge for special handling and disposal).		Yes No
Additional Information: