ALLIANCE TECHNOLOGIES -

Sample Submission Form

Please complete this form when submitting your samples to the lab for testing. Pack samples according to all applicable shipping requirements and send to Sample Intake at Alliance Technologies

First Name*

Last Name*

Title/Position

Email*

Phone*

Account*

Address

City

State

ZIP

Country

Payment Option*

ACH (Call for Info)

Credit Card (Call to Submit)

PO (Pre-Approval Required)

PO #

Billing Address

Project Objective*

Sample Type*

GxP Status*

NON-GxP

GMP (Specify Validated Method below)

GLP

Sample Background Info*

Storage Conditions*

No Special Conditions

Refrigerate

Freeze

Other

Other Storage

Sample ID's*

Sample Return*

No (discard)

Yes (charges apply)

Turnaround Time*

Normal (5-10 Business Days)

Rush (<5 Business Days)**

Priority (<3 Business Days)**

Comments*

TERMS: Payment due upon completion of the tests and/or delivery of the results and subject to the standard terms and conditions of Alliance Technologies. Pre-payment may be required for new clients until credit established. Samples may be sub-contracted at the discretion of the laboratory. Submission of this form for testing services assumes agreement with these terms and conditions and the pricing information provided by Alliance Technologies.