University of Alberta  
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Analysis Request Form

Company: Department:

Person requesting analyses Title:

Shipping address *NO P.O. BOXES* :

Telephone number: Facsimile number:

Electronic mail address:

Invoicing address:

Your purchase order number:
Results will not be released until
purchase order number is received

Turnaround requested: Normal
(Results generally within 14
days of sample receipt)
72 hour
50% Surcharge
(minimum verbal report within
three business days of sample receipt)
24 hour
100% Surcharge
(minimum verbal report within
one business day of sample receipt)

Describe the problem:

Analyses required (if known):

Sample description:

Discard sample(s) after analyses?: Yes No
Return sample(s) after analyses: Yes*
*$10.00 CAD for Canadian shipments
will be added to invoice
Report format: Hard Copy Facsimile Electronic Mail
  Floppy Disk *
*$2.00 CAD will be added to invoice
Compact Disk by Courier *
*$10.00 CAD will be added to invoice
Sample submission guidelines: 1. Samples and area(s) of analysis should be clearly marked and labeled

2. Samples should be clean (i.e. free of finger prints, dirt, debris), and wrapped separately

3. A surcharge of $25.00 CAD will be levied when obvious dangerous/hazardous goods arrive in our facility without the appropriate Dangerous Goods Declaration and MSDS

Your name: Date: