APPLIED CONSUMER SERVICES, INC.
11890 N.W. 87 COURT, UNIT #8, HIALEAH GARDENS, FL 33018
Phone: (305) 821-1677 Fax: (305) 821-0155 E-Mail: info@appliedconsumer.com

SAMPLE RECEIPT / CHAIN OF CUSTODY

Samples received on the ___________day of ___________, 20_______.

List of samples:

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Received by: ________________________ Date: _______________

Delivered by: ________________________ Date: _______________

Witnessed by: _______________________ Date: _______________