Sample Drop Off Form

1

Submitting for:

PersonalCompany

2

Company Name

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 ;)

YESNO

4

Project Number or PO:Example: Unit 201, Marlborough, 1200 5th St SW, etc.

optional

5

Name* This field is required.

First Name

Last Name

6

Email* This field is required.To send the report

example@example.com

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Phone Number* This field is required.

8

Address* This field is required.Sampling Location

9

Different Billing Address?

YESNO

10

Billing Address

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

12

SamplesExample: Popcorn Ceiling in Bedroom

Sample 1

Sample 2

Sample 3

Sample 4

13

Samples ContinuedExample: Clean Room Jan 21

Sample 5

Sample 6

Sample 7

Sample 8

14

Samples Continued AgainExample: Final Clearance Today

Sample 9

Sample 10

Sample 11

Sample 12

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sampleNumber

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How soon do you need results?* This field is required.

1 Week - $45/sample

1 Day - $65/sample

RUSH Today - $150/sample

17

TotalPlease Note: We require payment before we release the results.

Total cost including GST. All charges in CAD.

18

Invoice ID

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Signature* This field is required.

Clear

20

Payment

In OfficeInvoice

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Pay Now?* This field is required.Click "NO" to be sent an invoice for payment later. Click "YES" to use our integrated PayPal Checkout on your phone!

YESNO

22

Checkout

Description

CAD

+ OR enter a custom value

Checkout

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23

Date

Hour

Minutes

24

Date of Receipt

25

PhoneN

26

TAT

3 Hour

24 Hour

72 Hour

27

Date to Complete

Date

28

Notes