Sample Shipment to:
15 Wiggins Avenue, Bedford, MA 01730
MICROBIOLOGY TEST REQUISITION FORM
Ph: (781) 275‐3330 FAX: (781) 271‐1138
Section 1:
BILLING INFORMATION:
REPORT ADDRESSED AND MAILED TO:
Purchase Order No.:_____________________________________________
Company Name:________________________________________________
Quotation No.:_________________________________________________
Company Contact:______________________________________________
Billing Address (if different):______________________________________
Address:______________________________________________________
City:____________________________State:___________ZIP:___________
City:___________________________State:____________ZIP:___________
Billing Comments:______________________________________________
PH:______________________________FAX:_________________________
_____________________________________________________________
Email Address:_________________________________________________
Section 2:
TEST ARTICLE IDENTIFICATION (
:
Storage Condition:
Exact wording will be in final report)
Room Temp.
4°C±2°C
‐20°C±4°C
‐80°C±10°C
TEST ARTICLE NAME:____________________________________________
_____________________________________________________________
Other Temp:___________________
LOT/BATCH No.:________________________________________________
DISPOSITION of TEST/CONTROL ARTICLE:
Total Quantity Submitted: _________________________
Discard
Return unused
Return used & unused
Sample Submitted is:
Sterile
Not Sterilized
If samples to be returned, please provide shipping account info.:
UPS
FedEx
Other:___________
Acct.#______________________
Note: Unless specified on the test request form, 1) all samples will be stored at room temperature, 2) all samples will be disposed of without prior notice to
Sponsor, and 3) If Sponsor does not provide shipping account number, then Sponsor will incur a minimum of $125 per shipment of returned test article
STUDY DIRECTOR: ___________________________________________________________________
DATE:_______________________________
TOXIKON PROJECT NUMBER:___________________
LOGIN INITIALS__________________
LOGIN DATE:_________________________
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