Wine Analysis Request Form

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OFFICE USE ONLY
DR
FC
COMP
TSR
RSH
640 Airpark Road, Suite D
Yes
Napa CA, 94558
Have you submitted samples to us in the past?
Lab (707) 224-7903 ext. 306 or 307
IF YES, PLEASE FILL OUT ONLY THE (**) MARKED INFORMATION FIELDS
Fax (707) 255-2019
No
IF NO, PLEASE FILL OUT THIS FORM COMPLETELY
WINE ANALYSIS REQUEST FORM
PLEASE LABEL EACH SUBMITTED SAMPLE WITH YOUR WINERY NAME, SAMPLE NAME, AND SUBMISSION DATE
PLEASE FILL OUT THE REQUIRED INFORMATION ON BOTH SIDES OF THIS FORM AND SEND OR BRING WITH YOUR SAMPLES
MINIMUM ANALYSIS CHARGE: $25.00 FOR TRANSACTIONS PAYING BY CASH, CHECK, OR CREDIT CARD. $50.00 FOR NET 30 DAY TERMS
**
ACCOUNT NAME (Responsible Party)
**
NAME (Person requesting analysis)
ADDRESS:
CITY
STATE
ZIP
**
DAYTIME PHONE
**
FAX
**
EMAIL
CREDIT CARD #
EXP DATE
NAME ON CARD
SIGNATURE
**
SEND RESULTS TO (If different from above)
**
PLEASE SEND RESULTS BY
FAX
E-MAIL
MAIL
circle choice(s)
YES
I am not sure which test to run (please write a note or call
ARE THESE SAMPLES
PLEASE CHECK ALL THAT
our lab staff to discuss the sample)
INVOLVED IN A LEGAL DISPUTE
APPLY
Do only the tests I select
BETWEEN TWO PARTIES?
NO
Other
circle choice
COMMENTS
Please write the corresponding letter of the analysis you would like performed after the sample name in the table below.
Please refer to our webpage ( ) or current catalog for instructions on preparing, sending in your samples, and volume of sample required.
**
SAMPLE NAME
TEST CODE(S) OF REQUESTED ANALYSES
**
SAMPLE NAME
TEST CODE(S) OF REQUESTED ANALYSES
1.
6.
2.
7.
3.
8.
4.
9.
5.
10.

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