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Sample Drop-Off Form
Hi there, please fill out and submit this form as a Chain of Custody (COC) before dropping off samples at our office location.
7
Questions
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1
Submitting for
Personal
Company
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2
Company Name
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3
Do we already have your info?
If you've submitted samples before, let us know and we will spare you filling out your info again ;)
YES
NO
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4
Project Number or PO
Example: Unit 201, Marlborough, 1200 5th St SW, etc.
optional
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5
Name
*
This field is required.
First Name
Last Name
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6
Email
*
This field is required.
To send the report
example@example.com
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7
Phone Number
*
This field is required.
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8
Address
*
This field is required.
Sampling Location
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9
Different Billing Address?
YES
NO
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10
Billing Address
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11
Types of Samples
*
This field is required.
What type of sample are you dropping off?
Building Materials (Asbestos)
PCM Air Samples
Mould Samples
Lead Samples
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12
Air Sample List
*
This field is required.
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13
Bulk Sample List
*
This field is required.
Click "+ADD" button after typing in each sample!
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14
sampleNumber
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15
How soon do you need results?
*
This field is required.
Time starts upon receipt of samples during business hours
1 Week - $45/sample
1 Day - $65/sample
RUSH Today - $150/sample
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16
Turnaround Time
*
This field is required.
Time starts upon receipt of samples during business hours
RUSH - Same Day
Regular - Next Business Day
2 Business Days
5 Business Days
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17
Total
Please Note: We require payment before we release the results.
Total cost including GST. All charges in CAD.
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18
Invoice ID
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19
Signature
*
This field is required.
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20
Payment
In Office
Invoice
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21
Pay Now?
*
This field is required.
Click "NO" to be sent an invoice for payment later. Click "YES" to use our online checkout!
YES
NO
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22
Checkout
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( X )
Description
CAD
+ OR enter a custom value
Checkout
loading smart payment buttons...
The payment is ready! It will be completed once you submit the form.
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23
Date
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Minutes
AM
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24
Date of Receipt
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25
PhoneN
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26
TAT
3 Hour
24 Hour
72 Hour
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27
Date to Complete
-
Date
Month
Day
Year
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28
Special Instructions or Notes
Example: separate layers, samples being mailed in, etc.
May affect sample price if additional analysis required
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Should be Empty:
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