USP Media &#038; Supplies Order Form &#8211; US Micro Solutions

USP <797> Monthly Surface Sample Kits

Ordering Information

This form is for current customers of U.S. Micro-Solutions. If you are not a current customer, we will request additional information to create an account for you with this order.

Orders are shipped Priority Overnight. Orders received after 1:00 p.m. will be shipped the next business day.
Are you a Current Customer?*

YesNo
Company Name*
Phone Number*

Area CodePhone Number
Email*
example@example.com
Name*

FirstLast
Alternate Shipping Address (if different from usual address)

Street Address

Street Address Line 2

CityState

Zip Code
Number of samples needed*
Date needed*

MonthDayYear
Date
Would you like this order to be set up as a monthly standing order?*

YesNo
Please provide the additional requested information to create an account with your order.
Name*

First NameLast Name
Company Name*
Principal Contact*

First NameLast Name
Title*
Principal Contact Phone Number*

Area CodePhone Number
Principal Contact Email*
example@example.com
Principal Contact Address*

Street Address

Street Address Line 2

CityState

Zip Code
Is your Billing information different than your Principal Contact information?*

YesNo
Billing Name*

First NameLast Name
Billing Phone Number*

Area CodePhone Number
Billing Email*
example@example.com
Billing Address (if different from Principal Contact address)

Street Address

Street Address Line 2

CityState

Zip Code
Is your Shipping address different than your Principal Contact address?*

YesNo
Shipping Address*

Street Address

Street Address Line 2

CityState

Zip Code
Billing Preference*

Credit Card ♦Company Check
♦ Please call 724-853-4047 to provide a credit card number.
Number of samples needed*
Date needed*

MonthDayYear
Date
Would you like this order to be set up as a monthly standing order?*

YesNo
Choose a ship date for the kit - the 1st or 15th of each month. If the selected date falls on a weekend or a holiday, the kit will be shipped on the next business day.*
Indicate any months when a kit should not be shipped, e.g, biannual certification.
USP 797 requires that competency in surface sampling be demonstrated annually. If you would like to order EnverifyTM Surface Sampling Competency Kits, please specify the number needed.
Should be Empty:

USP <797> Monthly Surface Sample Kits

Ordering Information

Please provide the additional requested information to create an account with your order.