ALTECA Ltd.   

 
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Sample Submit Form - Feed Samples

 

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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

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)

Lot #/Sample ID #: ________________________________________________
Description of the Material: ________________________________________________

Services Desired:        (Check all that apply)

Qualitative Analysis Quantitative Analysis
Ingredient Examination, written opinion _______________
Feed Tag Verification _______________
Rendered Animal Contamination (BSE Screening) _______________
Rendered Animal Contamination (FDA-BSE exam) _______________
Adulterants & Contaminants _______________ _______________
Formula Feed Ingredient Identification _______________ _______________

_______    Photo-documentation; photographic record of sample; additional charges will apply

Sample Disposal:    (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 (2 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 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 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