Before filling out this form, please type the characters displayed above:

1. Please provide the following contact information

   First Name	*
   Last Name	*
   Organization
   Street Address	*
   Address (cont.)
   City	*
   State/Province	*
   Zip/Postal Code
   Country
   Work Phone	*
   Home Phone
   FAX
   E-mail
   URL

   
   
2. Please the list the type(s) of sample you wish to have tested

    *
   

3. For each type of sample listed please estimated the number of samples per period you will submit for testing 
   ( e.g. Tank Water - 1 sample only, Meat - 5/week, Water - about 30/month etc)

   
   

4. Select any of the following analyses to be performed - Note if the analysis does not appear in this limited list add it to the comments section at the bottom of this form

   Anaerobic Plate Count                              Bacillus cereus                                    
   Brochothrix thermosphacta                          Campylobacter                                    
   Chemical Tests (detail in Comments section below)  Clostridium perfringens                            
   Coliforms                                          Escherichia coli (E. coli)                       
   E. coli O157:H7                                    Enterobacteriacae                                  
   Enterococci                                        Faecal Coliforms                                 
   Faecal Streptococci                                Fungal count                                       
   Lactic acid bacteria                               Legionella                                       
   Listeria                                           Osmophilic yeast and moulds                        
   Plate count (Total bacteria count)                 Pseudomonas (foods)                              
   Pseudomonas aeruginosa (water)                     Psychrotrophic organisms                           
   Salmonella                                         Slime-forming bacteria                           
   Staphylococcus (coagulase positive)                Thermophilic plate count                           
   Thermoduric plate counts                           Vibrio parahaemolyticus                          
   Yeast and moulds                                   Yersinia enterocolitica                            

5. If there are any special processing requirements or specific methods to be used, please specify.

   
   

6. How urgent is this request

   Within the next 5-7 days will be fine In the next 2-3 days please As Soon As Possible please URGENT - Call me today if possible
   

7. Please list any other comments or requirements