Spectrex Corporation - 650-365-6567 Water Testing
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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.
Additional Information: