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Contact Name(s):
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Company Name:
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Street Address:
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City: State: Zip code:
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Phone(s): Fax:
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E-mail:
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How did you find us?
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Sample(s) description:
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Concentration:
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Lot (Batch) Number(s):
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Expired:
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Analysis/Test (Planned):
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Storage Condition: RT ( ) Refrigerator ( ) Freezer ( )
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Samples Disposition: Discard ( ) Return/Extra charge ( ) Store/Extra charge ( )
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Contract: Non-Disclosure Agreement:
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Status of the Project: Legal ( ) Patent ( ) Deformulation ( ) MCB/Sterility ( )
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Failure/Forensic ( ) Nutrition ( ) Shelf Life/Stability ( ) QC ( ) Other ( )
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Turnaround Time (Planned): Rush: 24-48 hr ( ) 3-5 days ( ) 6-10 days ( )
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Report: Verbal ( ) Faxed ( ) Mailed ( ) Picked up ( ) E-mailed ( )
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Invoice: Original ( ) Faxed ( ) Not needed ( )
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Laboratory Fee: Retainer: Total:
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I accept the Conditions and Term for This Project:
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Signed: Date:
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Print Name:
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