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