Company Name: Record the name of your company.
Address: Record the
address to which the hard copy of report is to be sent.
(Include billing address if different)
Project Name: Enter your
company’s project name and/or location associated with the
Contact: Record the name
of the person to receive the hard copy of analytical
Telephone: Enter the
telephone number to be used when reporting analytical
Fax: Enter the fax number
to be used when reporting analytical results.
Sample Type: Indicate
Sample Number: Enter the
sample identification number for each sample to appear on
Sample Description or
Location: Enter the sample description or location for
each sample. (ie– window sill, southeast wall)
Collection Date: Enter
the month and day of sample collection.
Method: Enter the type of
sample to be analyzed. (ie– Anderson, HVAC, Tape, Bulk,
Swab, Contact, etc.)
Sample Time: Enter length
of sample collection time.
Flow Rate: If applicable,
enter the flow rate of equipment used for collection.
Analytical Request: Enter
the analysis for which you wish the sample to be tested.* (MBI
1, MBI 2, MBI 3, etc…)
Media: Indicate the type
of Media used. (ie-Malt Extract, TSA, etc.)
Method of Payment:
Visa/MC/Am. Ex. (circle one). SIGNATURE OF CARDHOLDER IS
REQUIRED. Enter the card number and expiration date.
PO# (if applicable): If
chosen as method of payment, MBI requires a formal Purchase
Order to be submitted with
Released by: Signature of
person releasing samples.