On-line Sample Submittal Form

Company Name:

Date:
Submitter Name:
 
Address:

150 characters allowed  character countdown
Telephone:
Fax:
Email:
YOUR MATERIAL CODE NUMBER OR DESCRIPTION YOU WANT TO APPEAR ON THE REPORT
Please choose 12 initial characters to appear on the data report sheet

-----------------------------INSTRUCTIONS TO LABORATORY-----------------------------

Which delivery service do you want? Standard
20-30 Business Days
  Advance10-14 Business Days
  Priority 6 Business Days – limited availability
  BETA 3 day 1-3 Business Days – limited availability, pre-arrangements required
  BETA 1 day 24 Hour Delivery – limited availability, pre-arrangements required
Are you SURE the submitted material is well mixed and representative of the product? Check for YesWhen submitted materials contain multiple organic components, it is imperative that the material be well mixed and representative of the proportions of components in the final product.
What is the material type?

Solid

 
  Fluid Fuel/fuel additive (check for YES)
  Gas Contact the laboratory before sending gases or vapors
What are you sending the material in? Its retail packaging 
  Glass/plastic bottle  
  Plastic bag  
  Other Describe
Is the material more than 15% carbon? Check for YES if the material is > 15% carbon
Check for NO
Is the material flammable? Check for YES if the material is flammable
Check for NO
Does the material contain volatile organics such as ethanol? Check for YES
Check for NO
 Describe type and content of volatile organics.

character countdown
Does the material contain non-combustible organics such as graphite? Check for YES
Check for NO
 Describe type and content of volatile organics.

character countdown

The following information is not required but will assist us in providing you with the most efficient and cost effective analysis.

Material/Product name
Approx. submitted weight or volume:
Be sure to designate units – grams, oz, ml, etc..
Approx. percent carbon content:
weight carbon to total weight of material
Approx. percent water content:
weight or volume of water to total weight or volume of material
Approx. percent alcohol content:
weight or volume of alcohol to total weight or vol. of material

-----------------------------Payment Information-----------------------------

Not all options may be available to you, depending upon origin of payment or credit history. Credit card is the prefered method of payment. If you have special billing instructions (3rd party, multiple invoices, etc), please include those in the "other/special billing requests" box.

Method of Payment: Send Invoice against P.O.
  Send Invoice without P.O. (only available in special cases)
  Credit Card
  Check
  Bank - Wire Transfer
  Other/Special Billing Requests:
Purchase Order #:
Name on Credit Card
Credit Card #:
Exp. Date:
Special Instructions: