Click here to download a copy of the form in PDF format.

PLEASE KNOW THAT MBI DOES NOT ACCEPT DELIVERY ON SATURDAY OR SUNDAY. BUSINESS HOURS ARE: 9AM - 5PM (CST)

Field Data Sheet / Chain of Custody Instructions -

  1. Company Name: Record the name of your company.

  2. Address: Record the address to which the hard copy of report is to be sent. (Include billing address if different)

  3. Project Name: Enter your company’s project name and/or location associated with the samples.

  4. Contact: Record the name of the person to receive the hard copy of analytical results.

  5. Telephone: Enter the telephone number to be used when reporting analytical results.

  6. Fax: Enter the fax number to be used when reporting analytical results.

  7. Sample Type: Indicate sample type.

  8. Sample Number: Enter the sample identification number for each sample to appear on report.

  9. Sample Description or Location: Enter the sample description or location for each sample. (ie– window sill, southeast wall)

  10. Collection Date: Enter the month and day of sample collection.

  11. Method: Enter the type of sample to be analyzed. (ie– Anderson, HVAC, Tape, Bulk, Swab, Contact, etc.)

  12. Sample Time: Enter length of sample collection time.

  13. Flow Rate: If applicable, enter the flow rate of equipment used for collection.

  14. Analytical Request: Enter the analysis for which you wish the sample to be tested.* (MBI 1, MBI 2, MBI 3, etc…)

  15. Media: Indicate the type of Media used. (ie-Malt Extract, TSA, etc.)

  16. Method of Payment: Visa/MC/Am. Ex. (circle one). SIGNATURE OF CARDHOLDER IS REQUIRED. Enter the card number and expiration date.

  17. PO# (if applicable): If chosen as method of payment, MBI requires a formal Purchase Order to be submitted with samples.

  18. Released by: Signature of person releasing samples.

* Please refer to your price and service list or call MBI for further information.

    


100 Commons Road, Ste. 7354 Dripping Springs, TX 78620 Phone: 1-800-272-3716