submission form

Agdia Testing Services Sample Submission Form


Agdia Incorporated 30380 County Road 6 Elkhart, Indiana 46514 USA	Phone: 1-800-622-4342 Fax: 574-264-2153 e-mail: testing@agdia.com

Please submit samples via overnight courier (Fed Ex, UPS, etc.)

Sample Submitted by:

Submitter's Name:_________________________________________________
Company Name:_________________________________________________________
Address:_______________________________________________________________
City:__________________State:_______Zip:_________
Phone:______________________Fax:_____________________ Email:__________________

Send invoice to: Check here if same as above [ ]

Company:____________________________________________Attn:_____________________
Address:_______________________________City:_______________State:_______Zip:___________

Method of payment:

[ ] Bill to purchase order number:____________________________
[ ] Check Enclosed
[ ] American Express [ ] Visa [ ] Mastercard Account Number:________________________
Exp. date:__________Cardholder's Signature:_________________________

Send extra copy of report to:

All results are confidential to submitter. A copy of the report will automatically be sent to submitter via fax and mail. If you want someone else to receive a copy please complete this section. This section must be completed if releasing results to parties other than the original submitter.

Name:____________________________________________________________________________
Address:_______________________________________________________________________
City:____________________________________ State:_______ Zip:_________
Phone:_____________________Fax:____________________ Email:_________________
Submitter's name (print):______________________ Signature:_________________________

Sample identification:

(e.g. Impatiens 'agdia medley' 001) For multiple requests use multiple forms.

Sample I.D. Sample I.D.
1 6

2 7

3 8

4 9

5 10

	Sample I.D.		Sample I.D.
1		6
2		7
3		8
4		9
5		10

Test(s) requested*:

__________________________________________________________________ *If you are not sure which pathogens to test for, we recommend one of our screens. These contain tests for frequently encountered viral pathogens of a particular crop. Please feel free to call us to ask which screen suits your crop best.