Test/Sample Request - Bionetix International

Company Name*
Date*
MM slash DD slash YYYY
Name*
First Last
Email*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*
How would you like to receive your results?*
- Email
- Mail
- Fax
Please choose one:*
- End-user Company
- Distributor
- Cortec/Bionetix
Customer Deadline*

Note: Microbial testing ranges from 24 to 48 hours. Total laboratory time is microbial testing time + 5-10 business days from date samples and all required information are received. Cortec will let you know if deadline is achievable or if alternative deadline will be required.
Describe the GOAL of the test, customer application and usage:*
Does the customer REQUIRE a specific test method be used:*
- Yes
- No
List specifics for each fluid or product sample to be tested as detailed below and include SDS and Product Data Sheet for all applicable chemicals sent to laboratory:
Sample ID*
Mfr*
Brand*
Dilution (%)*
pH*
Method*
Specification*
List specific SAMPLES that will be sent to Bionetix Laboratories. Returns will not be possible.
Sample ID*
Description of Sample*
Quantity*
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