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Credit Card Submittal Form - Excel

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Credit Card Submittal Form - Excel Powered By Docstoc
					                                     Microbac Laboratories, Inc., Hauser Laboratories Division
                                     4750 Nautilus Court South, Unit A, Boulder, CO 80301 Ph: 720-406-4800 Fax: 303-581-0195                    Project Reference:
                                                                                                                                                   (Microbac Use Only)

                                           Microbiological Sample Submittal Form
                    Client Information                                         Billing Information                                    Method of Payment
Contact:                                                     Address:                                                          PO #
Company:                                                     (if different)
Address:                                                                                                                       Check #
                                                             Phone:
Phone:                                                       Fax:                                                              Credit Card
Fax:                                                         A/P Contact:
Email:                                                                                                                Hauser Contact:
                           Sample Information                                      Analysis Required: Please check below or list the testing required
               Sample                 Collection Sample         # of     APC Total E. coli E. coli Salmo- Staph Yeast Listeria Lactic               Other
            Identification           Date Time    Type        Containers     Colif         O157 nella aureus & Mold                  Acid         Please List




Comments / Special Testing Requirements:


Submitted By (signature):    Date:                 Received By (signature):            Date:                  Date Results Needed By:


Submitted By (signature):    Date:                 Received By (signature):            Date:                  Results Requested By:
                                                                                                                               Phone            Fax              Email
Submitted By (signature):    Date:                 Received By (signature):            Date:
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                                                                                                                                                      HL 4000 MSSF.002

				
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Description: Credit Card Submittal Form document sample