Service Form

Analysis Service, C/O
Spectrex Corporation
3790 EL CAMINO REAL # 308
PALO ALTO, CA 94306

Phone: 650-365-6567

WE DO NOT ACCEPT ANY HAZARDOUS MATERIALS.

Please fill out the form below, and click on 'Submit' to print final format for shipping with samples:

Ship approximately 100 mL, or 6 oz per sample in well sealed plastic container(s). - It is very important to label all bottles, containers and packages.

Referred by:
Date:
Submitted by (Full Name):
Title of Sample(s):
Number of Samples:

SEND RESULTS TO:
Company Name:		Attention:
Phone:		Fax:
E-mail:

BILL TO:	(Visa, American Express, MasterCard accepted)	Purchase Order #:	**
Company/Cardholder's Name:		Attention:
Card Number:	Write on this form once printed. (for security purposes)	Expiration Date:	/
		Card Verification Number	Click here for help.
Address:
City:		State:
Country:		Zip:
Phone:		Fax:
** NOTE: If your Accounts Payable Department requires a Purchase Order Number for payment it MUST be provided on this form.


I want to order discounted label/bottle kits. (Check price window for discounts)		Yes, please call me. How many?

Additional Information: