Note: required information is marked with an *
* Your Name
* Company Name
* Street Address
* P.O. Box
* City / State / Zip
* Telephone Number
* Email Address
Are the containers being shipped to you at the address above? If No, please enter the Shipping Address where you want the containers delivered.
* Shipping Addressyes no
Will the Results go to you at the address at the top of the screen? If No, please enter the reporting address where you want the results mailed to.
* Reporting Addressyes no
Will the bill for these analyses go to you at the address at the top of the screen? If No, please enter the billing address where you want the results mailed to.
* Billing Addressyes no
* Number of Samples
* Type of Sample
(if other, please specify)

Analytical Parameter(s)
(if you are not sure please call the laboratory 319/335-4500)
Analytical Method(s)
(optional - if you want or are required to have the analysis run by a certain method, please list it here)
Other Information or Comments