Sample Information Sheet printable pdf download

Sample Information Sheet

HOLMES LABORATORY, INC.

( USE THIS FORM FOR ALL SAMPLES EXCEPT SOIL )

(330) 893-2933 or (330) 893-1326

Complete and Submit with Samples and Payment.

Please Print:

Shipping Address:

Company or Farm Name:___________________________________________________

UPS/FED EX

US MAIL,

Name: _______________________________________________________

3559 US Rt. 62

Millersburg, OH 44654-8834

Address: _______________________________________________________

Payment Information

City: _____________________________ St.______ Zip _____________

Payable To:

E-mail: _______________________________________________________

_______ Cash

Check, No. ______________ Holmes Lab, Inc.

Phone: ________________________ Fax: _________________________

Visa ________ Mastercard ________ Discover ________ Amex. ________

Please mark an X that indicate your choice (s ) for receiving the test results.

___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___

__________ Reg. Mail

____________ Fax

____________ E-mail

Exp. Date: ________________

Amount: $____________________

Lab Use Only

Customer

Lab Code

Sample Description

Test Desired

Cost

___________________________________________________________________________________________________________________________________________________________

Sample Information Sheet

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