SAMPLE SUBMISSION FORM

Please fill out all fields and email the form. Place a copy with the shipment.

CUSTOMER INFORMATION

COMPANY

CONTACT

ADDRESS

ADDRESS 2

PHONE NUMBER

FAX NUMBER

CHAIN OF CUSTODY SAMPLEYESNO

BILLING INFORMATION

COMPANY

CONTACT

ADDRESS 1

ADDRESS 2

PHONE NUMBER

FAX NUMBER

ATTN TO

PO#

DATE

SUBMITTED BY

SIGNATURE

PRINT NAME

SAMPLE DESCRIPTION

SAMPLE DESCRIPTION 1

SAMPLE SIZE 1

ANALYSIS 1

CLAIMS 1

OTHER 1

SAMPLE DESCRIPTION 2

SAMPLE SIZE 2

ANALYSIS 2

CLAIMS 2

OTHER 2

SAMPLE DESCRIPTION 3

SAMPLE SIZE 3

ANALYSIS 3

CLAIMS 3

OTHER 3

SAMPLE DESCRIPTION 4

SAMPLE SIZE 4

ANALYSIS 4

CLAIMS 4

OTHER 4

SAMPLE DESCRIPTION 5

SAMPLE SIZE 5

ANALYSIS 5

CLAIMS 5

OTHER 5

SAMPLE DESCRIPTION 6

SAMPLE SIZE 6

ANALYSIS 6

CLAIMS 6

OTHER 6

SAMPLE DESCRIPTION 7

SAMPLE SIZE 7

ANALYSIS 7

CLAIMS 7

OTHER 7

SAMPLE DESCRIPTION 8

SAMPLE SIZE 8

ANALYSIS 8

CLAIMS 8

OTHER 8

SAMPLE DESCRIPTION 9

SAMPLE SIZE 9

ANALYSIS 9

CLAIMS 9

OTHER 9

SAMPLE DESCRIPTION 10

SAMPLE SIZE 10

ANALYSIS 10

CLAIMS 10

OTHER 10

SAMPLE DESCRIPTION 11

SAMPLE SIZE 11

ANALYSIS 11

CLAIMS 11

OTHER 11

SAMPLE DESCRIPTION 12

SAMPLE SIZE 12

ANALYSIS 12

CLAIMS 12

OTHER 12

ADITIONAL INSTRUCTIONS

LIMITATION OF LIABILITY.
Vertex Analytical Labs shall no liable for any claim or right to recover damages, including, but not limited to, loss of material, profit or special incidental, or consequential damages, or other similar claims, even if Vertex Analytical Labs has been specifically advised of the possibility of such damages. Vertex Analytical Labs liability for damages shall be limited to the list price or the actual price paid for the test regardless of the form of the claim. By submitting you agree to Vertex Analytical Labs LLC Terms and Conditions, prices, notes, and limitation of liability above. Submitting samples also binds you to these Terms and Conditions, prices, notes, and limitation of liability.

SAMPLE SUBMISSION FORM

CUSTOMER INFORMATION

BILLING INFORMATION

SAMPLE DESCRIPTION

Important: By submitting this form you will receive a copy of this form in your email. Print it out and add it to the sample shipment.

SHIP SAMPLES TO:

9335 Airway Road, Suite 208 San Diego CA 92154

CONTACT US