Agdia Online Sample Submission Form

Sample Submitted By: (All Fields Required)

Submitters Name:      Company Name: 

Address: 

City:      State:      Zip: 

Phone:      Fax:      Email: 


Send Invoice To: (All Fields Required)

Please ensure that billing information contains the correct address for your accounts payable department. Late payment is subject to late fees and finance charges.
  Check if Same as Above

Please note, if invoice is being sent to a third party, the recipient of the invoice must sign off on the form prior to samples being tested by our laboratory.

Attn:      Company Name: 

Address: 

City:      State:      Zip: 

Phone:      Fax:      Email: 


Payment Method

Bill to Purchase Order: 

Check

Credit Card: If this payment type is selected you will receive a form via e-mail from norepy@agdia.com. Please print the form, fill in the credit card information, sign the form, and fax it back to Agdia at 1-574-264-2153. Do not email this form back for security purposes.

Upload your Sample Identification Spreadsheet. (Excel Files Only)

You can download a templatehereor upload an excel sheet of your own.

Upload Here

Click browse, select the excel file containing your sample information, then click OK.



Indicate what tests or screens you would like tested on your samples:

Reporting:

Beginning April 1st, 2014 all reports will automatically be sent to the sample submitter electronically. Hard copy reports can be mailed, optionally, for a fee of $20.00. If you wish to receive a hard copy of your report, please select the option below:

I wish to be mailed a hard copy of my report. By selecting this option I understand that a fee of $20.00 will be added to my invoice.

Send Extra Copy of Report To:

If you elect this option you will be required to fax this form back to Agdia with your name and signature authorizing us to send a copy of your report to a 2nd or 3rd party. Please note that there is a $20.00 fee for additional reporting.

Attn:

Company Name:

Address: 

City:      State:      Zip: 

Phone:      Fax:      Email: