Name: Phone: Email:
Full name Name of Company Address line 1 Address line 2 City State Zip Code Phone number Email Invoice to:
Same as Billing Address Enter your information
Enter your information Same as Billing Address
Method: Credit CardYes, Keep my credit card on file for future service. PO Required: YesNo Name on Card: Card Number Security Code Expiration CC Billing Address Additional Notes:
Tax Exempt: YesNo
Tax ID number
Phone:
Drug Test: UrineAlcoholDISAHairBloodNASAPNone
Safety/Site Specifics
HASCISTCPO Required before ServiceOtherNone
PPE Required: FRC LabcoatFRC CoverallsSafety GlassesHard HatSteel-toed shoesOtherNone
Please provide the recertification interval of your service. This determines "Next Due Date" on your reports.
Recertifcation Interval months Next Due Date Format: Quality Metrics: SO 17025 * ‡SO 9001 ‡U.S. PharmacopeiaNSF 49I don’t knowOther
* Would you like us to account for measurement uncertainty when determining pass/fail? YesNo
If so, Allometrics will provide three determinations: Pass, Fail, or Unknown - unless otherwise specified.
‡ Would you like Allometrics to determine pass or fail based upon specifications? YesNo Contact me later YesNo
Please provide the source of the specifications you would like us to use during our service:
Customer Shipping Account#:
Ship via: UPSFedExUSPSDrop off/PickupOther
Shipping method:
GroundPriority2nd DayOvernight
Questions? Call us or email sitespecifics@allometrics.com
allometrics.com (281) 609-7132
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