ALTECA Ltd.   

 
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Sample Submit Form

 

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Please print this page from your browser, fill it out completely and include it when submitting a sample for microscopic examination.  Call the laboratory at (785) 537-9773 before shipping the sample.  Please also read and follow our "Instructions for submitting a sample".

CONTACT INFORMATION: Please make sure that we have complete contact information for the person submitting the sample, the person(s) who should receive a copy of the results, the persons with whom we may discuss results, and to whom the invoice should be sent.  Attach additional sheets if necessary.  The party responsible for paying the invoice also controls the custody of the sample, including who is authorized to discuss sample results.  We will not discuss results with unauthorized persons. 

REPORT RESULTS TO:

Company Name: ________________________________________________
Contact Person: ________________________________________________
Address: ________________________________________________
________________________________________________
City, State, Zip Code: ________________________________________________
Telephone Number: ________________________________________________
Fax Number: ________________________________________________
E-mail Address: ________________________________________________
Report Results Via: _____ Fax       _____ E-mail        _____ Verbal Only (no written report to be issued)

SEND INVOICE TO:

_____   same as "report to"
Company Name: ________________________________________________
Contact Person: ________________________________________________
Address: ________________________________________________
________________________________________________
City, State, Zip Code: ________________________________________________
Telephone Number: ________________________________________________
Fax Number: ________________________________________________
E-mail Address: ________________________________________________
Purchase Order #: ________________________________________________

This form was completed by:

Name (Please print):  _____________________________________________________
Company/Title (Please print):  _____________________________________________________
Signature: _____________________________________________________
Date: _____________________________________________________

SAMPLE INFORMATION:    (fill in all that apply)

Claim #/Lot #: ________________________________________________
Claimant's Name: ________________________________________________
Date of Incident: ________________________________________________
Product Involved: ________________________________________________
Physical Description: ________________________________________________
i.e. glass, bone, black spot, hair, etc: DO NOT write "foreign material" - be specific

Provide a brief narrative of the circumstances surrounding this sample:

 

 

 

Services Desired:        (Check all that apply)

_______ Qualitative Microscopy; identify foreign object/foreign matter
_______ Forensic Microscopy; ID object and determine when/how it entered the product
_______ Photo Documentation; photographic record of sample
_______ Video Documentation; video record of sample and/or analysis
NOTE: additional charges will apply for photo and video documentation

Sample Storage:    (Please check one)        Click here to review our Sample Storage Policy

_______ Destroy after analysis All samples will be destroyed after 60 days if neither option below is indicated
_______ Place sample into Long Term Storage Freezer space may be rented for long-term sample storage; call the lab for details
_______ Return Sample after analysis A sample return charge will apply; please provide the complete physical address and telephone number below:
Return To: __________________________________________
___ same as "report to" address __________________________________________
___ same as "invoice to" address __________________________________________
__________________________________________

Priority:    (Please check one)

_______ Standard (4-6 weeks)
_______ RUSH (3-5 business days) Rush Service is billed at 1.5 times the normal charge.
_______ Same Day Rush Service is billed at twice the normal charge; prior arrangements must be made for this service.

Additional options:    (Check all that apply)

_______ Check here if you require NON-DESTRUCTIVE TESTING
_______ Check here if you require a CHAIN OF CUSTODY RECORD; Please enclose your company's chain of custody form when submitting the sample, OR see our chain of custody information.

Attach a separate sheet for any additional notes or comments.

Please let us know if the party shipping the sample is different from the contact information above, so that we can match up this form to the appropriate sample when it arrives.

Please ship samples to:   
ALTECA Ltd., 731 McCall Road, Manhattan, KS  66502
Tel: (785) 537-9773, Fax: (785) 537-1800, Click here to send an E-mail