Sample Request Form
After you fill out this sample request form, we will contact you to review the details and confirm the scheduled sample collection date and time. If you would like faster service or questions, please contact us at (888) 851-2617 or info@paclabanalytics.com
Email address *
Are you a new or existing customer?
Contact info
(Required)
Name of the contact person for this order *
Your answer
Street address where samples will be picked up *
Your answer
City *
Your answer
State *
Your answer
Zip Code
Your answer
Phone Number
Your answer
Preferred contact method *
Required
OLCC License Number (leave blank if the business is not OLCC licensed):
Your answer
OLCC License type
Scheduling Information
Please provide the date that you would like to schedule your sample collection and the number of batches
Number of batches to be sampled
Your answer
Date requested (For sample collection)
MM
/
DD
/
YYYY
Time requested (For sample collection)
Time
:
Sample Collection Information
This section is optional. By providing this information in advance, this will reduce the time needed to collect samples at your location. Space for 10 samples is provided. If you have more than 10 samples to submit, we can collect the additional sample information by email or in person.
1. Sample Name (strain name, batch name, or product name)
Your answer
1. Type of sample to be submitted (Check all that apply)
1. Tests requested (Check all that apply)
2. Sample Name (strain name, batch name, or product name)
Your answer
2. Type of sample to be submitted (Check all that apply)
2. Tests requested (Check all that apply)
3. Sample Name (strain name, batch name, or product name)
Your answer
3. Type of sample to be submitted (Check all that apply)
3. Tests requested (Check all that apply)
4. Sample Name (strain name, batch name, or product name)
Your answer
4. Type of sample to be submitted (Check all that apply)
4. Tests requested (Check all that apply)
5. Sample Name (strain name, batch name, or product name)
Your answer
5. Type of sample to be submitted (Check all that apply)
5. Tests requested (Check all that apply)
6. Sample Name (strain name, batch name, or product name)
Your answer
6. Type of sample to be submitted (Check all that apply)
6. Tests requested (Check all that apply)
7. Sample Name (strain name, batch name, or product name)
Your answer
7. Type of sample to be submitted (Check all that apply)
7. Tests requested (Check all that apply)
8. Sample Name (strain name, batch name, or product name)
Your answer
8. Type of sample to be submitted (Check all that apply)
8. Tests requested (Check all that apply)
9. Sample Name (strain name, batch name, or product name)
Your answer
9. Type of sample to be submitted (Check all that apply)
9. Tests requested (Check all that apply)
10. Sample Name (strain name, batch name, or product name)
Your answer
10. Type of sample to be submitted (Check all that apply)
10. Tests requested (Check all that apply)
Questions, comments, or special instructions
Your answer
A copy of your responses will be emailed to the address you provided.
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