Microbiology Test Requisition Form

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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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